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Introduction:The experience of terrorist incidents involving a secondary explosive device that targeted rescue forces led to changes in the safety protocols of these forces in most countries of the world. These protocols are the foundation of the current “Stage-and-Wait” paradigm that prohibits the entry of Emergency Medical Services (EMS) from entering the scene and treating casualties until it is deemed safe. These guidelines were established absent of an evidence-base detailing the risk to responders and the potential consequences to the injured on-scene. The lack of clarity is compounded by the fact that different situations, as well as operational considerations, such as the length of time until bomb squad arrival at the scene versus time of massive bleeding injuries, for example, impact outcomes must be taken into account.Objective:This study sought to shed light on this matter while employing an evidence-based approach exploring the investigations of the frequency of secondary explosion threats in terrorist attacks over the last 20 years and discussing some of the ethical challenges and ramifications ensuing. While this study does not propose an outright change to current guidelines, in light of the evidence gathered, an open review and discussion based on the findings may be beneficial.Methods:The Global Terrorism Database (GTD) was used as the data source of bombing incidents world-wide.Results:The results revealed that approximately 70 per-1,000 bombing incidents involved secondary explosions across regions and countries within the study period.Conclusion:This study emphasizes the need to rethink the current “Stage-and-Wait” paradigm by recommending brainstorming conferences comprised of multi-sectoral experts aimed at deliberating the matter. World-wide experts in emergency medicine, bioethics, and disaster management should cautiously consider all aspects of bomb-related incidents. These brainstorming deliberations should consider the calculated risk of secondary explosions that account for approximately 70 per-1,000 bombing incidents. This study highlights the need to re-examine the current versus new paradigm to achieve a better balance between the need to ensure EMS safety while also providing the necessary and immediate care to improve casualty survival. This ethical dilemma of postponing urgent care needs to be confronted.

Introduction:Asymmetric warfare and the reaction to its threats have implications in the way far-forward medical assistance is provided in such settings. Investments in far-forward emergency resuscitation and stabilization can contribute to saving lives and increase the resilience of health systems. Thus, it is proposed to extend the use of the Haddon Matrix to determine a set of strategies to better understand and prioritize activities to prepare for and set-up frontline care in the form of Trauma Stabilization Points (TSPs).Methods:An expert consensus methodology was used to achieve the research aim. A small subject matter experts’ group was convened to create and validate the content of the Haddon Matrix.Results:The result of the expert group consultations presented an overview of TSP Preparedness and Operational Readiness activities within a Haddon Matrix framework. Main strategies to be adopted within the cycle from pre- to post-event had been identified and presented considering the identified opportunities in the context of the possibility of implementation. Of particular importance was the revision of a curriculum that fits the civilian medical system and facilitates its adaptation to the context and available resources.Conclusion:The new framework to enhance frontline care preparedness and response using the Haddon Matrix facilitated the identification of a set of strategies to support frontline health care workers in a more efficient manner. Since the existing approach and tools are insufficient for modern warfare, additional research is needed.

Introduction Combat ground maneuvers consist of various platforms and have several environmental characteristics, influenced by the terrain, the operational mission, and the force’s capabilities. This study assesses data on injuries sustained during urban warfare, aiming to evaluate the relationship between injury characteristics, maneuver platform, and personal protective gear on the battlefield. Materials and Methods IDF soldiers injured infantry soldiers from the “Cast Lead” and the “Protective Edge” operations in the Gaza Strip (2008-2009 and 2014, respectively) were divided into four groups according to the maneuver platform and the environment: mounted infantry (armored and unarmored vehicle) and dismounted infantry (urban and open area). The primary outcome was the severity of the injury, and the secondary outcome was the injured body part. Results Overall, 588 casualties were included in the final analysis, of whom 507 were dismounted infantry soldiers (265 in open terrain and 242 in urban area) and 81 were mounted infantry soldiers (20 in unarmored and 61 were injured in armored vehicles). The Injury Severity Score was similar in all subgroups. Open terrain subgroups were found to have fewer head injuries and higher levels of lower extremity injuries, similar to the unarmored vehicle group. More facial injuries were documented in the urban area group. Conclusions The Injury Severity Score was not influenced by environmental protection. Although we found differences in the injured body parts, further studies on the exact mechanism of injury are needed to elucidate further the relationship and differences between the various platforms used and injuries seen in urban warfare, aiming for tailor-made protection.

Social resilience and trust are two major components of the mitigation of the spread of contagious diseases. Although measures such as the imposition of national lockdowns and self-quarantines have been proven to be effective in reducing morbidity, their efficacy is dependent on public trust and compliance. The purpose of this study was to assess public attitudes toward the COVID-19 outbreak over the course of a year. A cohort study of the adult population in Israel was conducted during three waves of COVID-19 morbidity in that country, with February 2020 as the baseline, March 2020 for the first wave, August 2020 for the second, and January 2021 for the third. The results suggest that there is a relationship between risk perception and compliance with health regulations. Moreover, trust is a major component in public compliance. Fluctuations in risk perception and trust were found to affect compliance with regulations. The failure of decision makers to appropriately address the economic constraints imposed on the public during prolonged disasters, such as the COVID-19 outbreak, is likely to lead to a reduction in public trust in the government and to a decrease in societal resilience.

Objective To estimate the potential influence of pre-operative patient condition on the benefit of earlier hip fracture surgery for elderly patients. Background Many studies emphasize the benefit of earlier hip fracture surgery for patient survival. However less is known regarding how this relationship is influenced by clinical factors which could serve as potential contra-indicators for earlier surgery. Rushed surgery of patients with contra-indications may even compromise their survival. Methods A retrospective study of patients aged 65 and above with an isolated hip fracture following trauma, based on data from 19 hospitals of the national trauma registry available for the years 2015–2016. Registry data was crossed with data on co-morbidities and medication intake from the biggest health insurance agency in the country, serving more than 50% of the country's population. Mediation analysis was performed on a wide list of co-morbidities, medications and clinical test results in order to establish the mediation of their relationship with inhospital mortality by earlier hip fracture surgery. Factors found significant in the mediation analysis were utilized to adjust a logistic regression for predicting inhospital mortality by function of waiting time to surgery and patient's sex and age. Results Anti-coagulant and anti-platelet intake; test results pointing to decreased kidney function and being diagnosed with diabetes or Ischemic Heart Disease were found to be significantly mediated in their influence on inhospital mortality by hip fracture surgery. Despite anti-platelet intake and kidney function having a significant impact on mortality in the multi-variate analysis, the positive effect of earlier hip surgery on survival remained unchanged after adjustment. Conclusions Earlier hip fracture surgery was found to be beneficial for elderly patients even when their co-morbidities and medication intake are taken into account.

Purpose::There is a common opinion that spinal fractures usually reflect the substantial impact of injuries and therefore may be used as a marker of significant associated injuries, specifically for intra-abdominal injury (IAI). The impact of concomitant spinal cord injury (SCI) with the risk of associated IAI has not been well clarified. The aim of this study was to evaluate the incidence and severity of IAIs in patients suffering from spinal fractures with or without SCI.Methods::A retrospective cohort study using the Israeli National Trauma Registry was conducted. Patients with thoracic, lumbar and thoracolumbar fractures resulting from blunt mechanisms of injury from January 1, 1997 to December 31, 2018 were examined, comparing the incidence, severity and mortality of IAIs in patients with or without SCI. The collected variables included age, gender, mechanism of injury, incidence and severity of the concomitant IAIs and pelvic fractures, abbreviated injury scale, injury severity score, and mortality. Statistical analysis was performed using GraphPad InStat ? Version 3.10, with Chi-square test for independence and two sided Fisher’s exact probability test.Results::Review of the Israeli National Trauma Database revealed a total of 16,878 patients with spinal fractures. Combined thoracic and lumbar fractures were observed in 1272 patients (7.5%), isolated thoracic fractures in 4967 patients (29.4%) and isolated lumbar fractures in 10,639 patients (63.0%). The incidence of concomitant SCI was found in 4.95% (63/1272), 7.65% (380/4967) and 2.50% (266/10639) of these patients, respectively. The overall mortality was 2.5%, proving higher among isolated thoracic fracture patient than among isolated lumbar fracture counterparts (11.3% vs. 4.6%, p < 0.001). Isolated thoracic fractures with SCI were significantly more likely to die than non-SCI counterparts (8.2% vs. 3.1%, p < 0.001). There were no differences in the incidence of IAIs between patients with or without SCI following thoracolumbar fractures overall or in isolated thoracic fractures; although isolated lumbar fractures patients with SCI were more likely to have renal (3.4% vs. 1.6%, p = 0.02) or bowel injuries (2.3% vs. 1.0%, p = 0.04) than the non-SCI counterparts. Conclusion::SCI in the setting of thoracolumbar fracture does not appear to be a marker for associated IAI. However, in a subset of isolated lumbar fractures, SCI patient is associated with increased risks for renal and bowel injury.

Objective: To compare injury patterns of different types of explosions. Methods: A retrospective study of 4508 patients hospitalized due to explosions recorded in the Israel National Trauma Registry between January 1997 and December 2018. The events were divided into 4 groups: terror-related, war-related, civilian intentional explosions, and civilian unintentional explosions. The groups were compared in terms of injuries sustained, utilization of hospital resources, and clinical outcomes. Results: Civilian intentional and terror-related explosions were found to be similar in most aspects except for factors directly influencing mortality and a larger volume of severely injured body regions among terror-victims. Comparisons between other groups produced some parallels, albeit less consistent. Civilian intentional explosions and civilian unintentional explosions were different from each other in most aspects. The latter group also differed from others by its high volume of life-threatening burns and a higher proportion of children casualties. Conclusions: While consistent similarities between explosion casualties exist, especially between victims of intentional civilian and terror-related explosions, the general rule is that clinical experience with a type of explosion cannot be directly transferred to other types.

BackgroundThe outbreak of a new Coronavirus disease (COVID-19) poses dramatic challenges to public health authorities worldwide. One measure put in place to contain the spread of the disease is self-quarantine of individuals who may have been exposed to the disease. While officials expect the public to comply with such regulation, studies suggest that a major obstacle to compliance for self-quarantine is concern over loss of income or employment due to the prolonged absence from work.MethodsA cohort study of the adult population of Israel was conducted in two time points during the COVID-19 outbreak, the last week of February and the third week of March 2020, in order to assess public attitudes. In particular, public compliance rates to self-quarantine with and without State-sponsored compensation for lost wages were assessed.ResultsThe results suggest that public attitudes changed as the threat increased, making people more compliant with regulations. In February 2020, compliance rate for self-quarantine dropped from 94% to less than 57% when monetary compensation for lost wages was removed; however, in March 2020 this drop became more moderate (from 96 to 71%). The multivariate logistic regression revealed that older, non-Jewish, worried over COVID-19, and trusting the Ministry of Health were more likely than their counterparts to comply with self-isolation, even when monetary compensation was not assumed.ConclusionsDespite the effects of threat on people’s obedience with regulations, this study demonstrates that providing people with assurances about their livelihood during absence from work remains an important component in compliance with public health regulations.

This study was primarily aimed at establishing the incidence and impact of hypotension in patients with blunt traumatic brain injury based on National Trauma Registry Database.A retrospective cohort study using the National Trauma Registry was conducted. Patients with TBI following blunt mechanisms of injury were examined, comparing those with and without hypotension (SBP90 mm Hg) on arrival.During the period from 1998 to 2017, the registry included 437.354 blunt trauma patients. Of them, 7818 patients were hemodynamically unstable (SBP90 mm Hg) on admission. 513 met the inclusion criteria. Significant percentages of patients with high grade injures (ISS≥16) and low admission's GCS 3-12 (46% vs 16.4%), were found in the group of hypotensive TBI patients (p0.0001). 323 (62.9%) patients had head AIS score 3-4 and only 190 (37.1%) patients AIS 5-6 (p0.0001). Mortality in the hypotensive TBI group was 32.3%, whereas 6.1% patients died in the TBI hemodynamically stable group (p0.0001).TBI patients presenting with hypotension represent an appreciable portion blunt trauma patients. Prompt brain CT, expedient efforts at optimal resuscitation and possibly early inotropic and vasopressors agents use may have an impact on final outcome in these patients.

To contain the novel coronavirus disease (COVID-19) pandemic, health and government authorities have imposed sweeping self-quarantine orders for communities worldwide. Health officials assume that the public will have high rates of compliance. However, studies suggest that a major obstacle to compliance for household quarantine is concern about loss of income. A cross-sectional study of the adult population of Israel was conducted in the last week of February 2020 to assess public attitudes toward the COVID-19 outbreak. In particular, public compliance rates with self-quarantine were assessed, depending on whether lost wages would be compensated for. When compensation was assumed, the compliance rate was 94 percent. When compensation was removed, the compliance rate dropped to less than 57 percent. This study demonstrated that providing people with assurances about their livelihoods during self-quarantine is an important component of compliance with public health regulations.

Early application of tourniquets has reduced injury death rates. At the end of 2013, the Israel Defense Forces Medical Corps completed a military-wide introduction of the Combat Application Tourniquet as the standard-issued tourniquet. The accompanying clinical practice guideline encouraged combat soldiers and medical teams towards a liberal use of tourniquets for extremity injuries, even when in doubt.This study aimed to assess the effects of the wide introduction of advanced tourniquets on the rate of tourniquet applications, the type of tourniquet applied, and the differences in hospitalisation outcomes following the introduction.The study population was composed of hospitalised military casualties with an extremity injury treated by military medical teams between 2006 and 2015. Prehospital data were extracted from the Israel Defense Forces Trauma Registry and matched to corresponding hospital data from the Israeli National Trauma Registry. Two periods were compared: 2006-2013 "pre-intervention period" and 2014-2015 "post-intervention period".A total of 1,578 casualties were recorded during the study period. Of these, 320 (20.3%) occurred between 2014-2015. Characteristics of casualties in the post-intervention period were similar to those in the pre-intervention period including the rate of traumatic amputations (2.5% vs 2.2%, p = 0.93) and Injury Severity Score of 16 or above (12.8% vs 14.9%, p = 0.40). The rate of tourniquet application was more than four-fold in the post-intervention period compared to the pre-intervention period (22.8% vs 5.5%, p 0.001). Nevertheless, rates of in-hospital amputations (1.6% vs 1.6%, p = 1.00) and death (0.9% vs 1.3%, p = 0.53) were similar in the two periods.Following the IDF military-wide introduction of advanced tourniquets, the tourniquet application rate rose sharply, the use of old tourniquets ceased over time, and in-hospital amputation rate did not increase. These findings suggest that the awareness for haemorrhage control using advanced tourniquets rose.

Diffuse axonal injury (DAI) is typically associated with significant mechanisms of injury and the effects of acceleration-deceleration forces on brain tissues. The prognosis of DAI remains a matter of active investigation, but little is known about outcome differences between adult and pediatric populations with DAI.We performed a retrospective cohort study involving blunt trauma patients with DAI between the years 1997 and 2018 from the Israeli National Trauma Registry. The patients were divided to pediatric (age15 years) and adult (age15 years) groups, with subsequent comparison of demographics and outcomes.Diffuse axonal injury was identified in 1983 patients, including 469 pediatric victims (23.6%) and 1514 adults (76.4%). Adults had higher Injury Severity Score (20.5% vs 13.2%, P = 0.0004), increased mortality (17.7% vs 13.4%, P0.0001), longer hospitalizations (58.4% vs 44.4%, P0.001), and higher rehabilitation need rates (56.4% vs 41.8%, P0.0001). Associated extracranial injuries were also more common in adults, particularly to the chest.Pediatric patients with DAI have improved outcomes and fewer associated injuries than adult counterparts.

Social resilience and trust are two major components of the mitigation of the spread of contagious diseases. Although measures such as the imposition of national lockdowns and self-quarantines have been proven to be effective in reducing morbidity, their efficacy is dependent on public trust and compliance. The purpose of this study was to assess public attitudes toward the COVID-19 outbreak over the course of a year. A cohort study of the adult population in Israel was conducted during three waves of COVID-19 morbidity in that country, with February 2020 as the baseline, March 2020 for the first wave, August 2020 for the second, and January 2021 for the third. The results suggest that there is a relationship between risk perception and compliance with health regulations. Moreover, trust is a major component in public compliance. Fluctuations in risk perception and trust were found to affect compliance with regulations. The failure of decision makers to appropriately address the economic constraints imposed on the public during prolonged disasters, such as the COVID-19 outbreak, is likely to lead to a reduction in public trust in the government and to a decrease in societal resilience.

Study objective The latest wave of terrorism worldwide has seen significant use by terrorists of mundane, "low-technology" weapons, such as utility knives and civilian vehicles. How do the injuries they produce compare with that of more conventional terrorism mechanisms, such as use of firearms and explosives? We compare injury patterns of the most frequent terrorism-related injury mechanisms in an Israeli data set. Methods This was a retrospective study of 1,858 patients hospitalized because of terrorism events, which were recorded in the Israeli National Trauma Registry between January 1997 and December 2016. The events were divided into 4 groups based on weapon used: explosions, shootings, stabbings, and vehicular attacks. The groups were compared in terms of injuries sustained, use of hospital resources, and clinical outcomes. Results Explosion-related and vehicular terrorism resulted in a higher proportion of multiple injuries, whereas stabbings and shootings mostly led to isolated injuries. Victims of vehicular attacks had a high proportion of severe head injuries, whereas stabbing victims had a high volume of vascular injuries. All mechanisms involved significant damage to extremities; however, among stabbing victims injury was mainly to the upper extremities, whereas among vehicular attack victims it was mostly to the lower extremities. The overall injury severity of the compared groups was similar, leading to comparable levels of intensive care use and inhospital mortality. Certain similarities in victims' characteristics were observed between the shootings and stabbings and between explosions and vehicular attacks. Conclusion Despite differences between various terrorist attack mechanisms, the resulting injury severity and inhospital mortality are very similar, with stabbings and vehicular attacks causing injuries as serious as those caused by conventional weapons.

Work absenteeism following an injury creates an economic burden on society and the individual. Programs encouraging return to work (RTW) should be implemented for high risk populations. The aim of this study was to identify the predictors for duration until RTW following an injury. The Israeli National Trauma Registry and the National Insurance Institute database (2008-2013) were linked. Logistic-regression models tested the probability not RTW within 1 month, 1 year and 2 years among 67% of the population and the quality of the model was examined among 33% of the population. The study population comprised 45,291 casualties (aged 21-67 and employed prior to injury as salaried workers). The majority of the study population (61%) RTW within 1 month from the injury event. Injury severity, multiple injuries, brain injury, traffic related injuries and fall injuries were significantly associated with work absenteeism. A dose-response relationship was found between income and not RTW: the lower the income the greater was the chance of not RTW. Among casualties with occupational injuries the odds for not RTW within a month, a year and 2 years were respectively, 3.7, 2.4 and 2 times significantly greater in comparison with casualties not injured at work. Underprivileged ethnic groups (Arabs and immigrants from Ethiopia) had a greater chance for long out of work stay following an injury. The outcomes of this study identified casualties at high risk for not RTW and enables health professionals to develop intervention programs focusing on returning to a productive lifestyle.

Objective: The objective of this study was to conduct a comprehensive analysis of demographics, injury characteristics and hospital resource utilization of significant pediatric electric bicycle (e-bike) injuries leading to hospitalization following an emergency department visit in comparison to pediatric injuries caused by other traffic related mechanisms.Methods: A retrospective review of all pediatric traffic injury hospitalizations following an emergency department visit to a level I trauma center between October 2014 and September 2016 was conducted. Data regarding age, sex, number of computed tomography (CT) scans obtained, number of major procedures, length of hospital stay (LOS), Injury Severity Score (ISS), and number of injuries per patient were collected and compared between e-bike injuries and other traffic injuries.Results: Three hundred thirty-seven admissions were analyzed: 46 (14%) were due to e-bike injuries (29% of patients >12 years). Age, proportion of brain injuries, and use o...

Introduction Bus public transportation is preferred for its perceived safety. Data from several countries, however, alarm of non-collision injuries associated with bus use. The aim of the current study was to estimate the prevalence of non-collision bus injuries, and compare and identify population group at high risk for severe injuries, to serve as a basis for policy makers. Methods A retrospective analysis of the Israeli National Trauma Registry cohort for the years 2015–2017 was carried out. Database consists of 20 hospitals nationwide. Casualties hospitalized following a non-collision injury on a bus were identified. Demographic, injury characteristics, and hospital resources utilization were compared according to the place of injury; inside the bus or during boarding or alighting. Results During follow up, 704 hospitalized non-collision related bus casualties were recorded. Most of the casualties (75%) fell inside the bus and 25% during boarding or alighting. The majority (67%) of hospitalized patients were 60 years old or above, mostly injured while boarding or alighting the bus, and 72% were women. Frequent injured body regions were lower extremities, head and torso. Passengers injured inside bus sustained more chest injuries, but less lower extremities injuries, compared to those boarding or alighting the bus. More hospital resources were required to treat passengers injured while boarding or alighting the bus. Conclusions This systematic registry-based analysis of non-collision bus injuries confirms the greater risk of being injured while using bus transportation among women and older passengers. Primary attention for prevention policies should be given to injuries occurring during boarding or alighting of the bus. Additional policy recommendations are discussed.

In response to increasing violent attacks, the Stop the Bleed campaign recommends that everyone have access to both personal and public bleeding-control kits. There are currently no guidelines about how many bleeding victims public sites should be equipped to treat during a mass casualty incident. We conducted a retrospective review of intentional mass casualty incidents, including shootings, stabbings, vehicle attacks, and bombings, to determine the typical number of people who might benefit from immediate hemorrhage control by a bystander before professional medical help arrives. On the basis of our analysis, we recommend that planners at public venues consider equipping their sites with supplies to treat a minimum of 20 bleeding victims during an intentional mass casualty incident.

Objectives To analyse the impact of hospital quality indicators on hip fracture mortality in Israel. Study design A retrospective observational study. Methods Data were collected on all patients aged ≥65 years with an isolated hip fracture in the years 2010–2016 from the Israel's National Trauma Registry. These data were then cross checked with information on co-morbidities and medication intake from the Clalit medical fund. All successfully matched patients constituted the study population. The main outcome measures were in-hospital and 1-year mortality. Trend analysis of surgery on hip fractures within 48 h of hospitalisation (referred to as early hip fracture surgeries) and mortality was performed. The introduction of the proportion of early hip fracture surgeries as an official quality parameter in 2013 was considered an intervention. Results The proportion of early hip fracture surgeries continuously increased during the study period and, after the introduction of the quality measure, a significant increase in the uniformity of practice among hospitals was observed. The mortality trend was not related to the early surgeries trend, with a sharp upward spike detected in 2014, followed by a gradual return to previous levels in the subsequent years. The analysis has shown that when adjusting for demographic factors and co-morbidity, both in 2010–2013 and in 2015–2016, a clear benefit in survival existed for patients who were operated on within the first 48 h. In 2014, which was the first year of open publication of achieved quality measures reported in the media, no such benefit was found. Conclusions Even when an improvement in a promoted practice is achieved, its positive impact on clinical outcomes may be delayed, possibly indicating the need for a learning period.

Study design A retrospective cohort study. Objective This study aims to assess the potential value of very early trauma variables such as Abbreviated Injury Scale and the Injury Severity Score for predicting independent ambulation following a traumatic spinal cord injury (TSCI). Summary of background data Several models for prediction of ambulation early after TSCI have been published and validated. The vast majority rely on the initial examination of American Spinal Injury Association)ASIA) impairment scale and level of injury, however, in many locations and clinical situations this examination is not feasible early after the injury. Methods Patient characteristics, trauma data and ASIA scores on admission to rehabilitation were collected for each of the 144 individuals in the study. Outcome measure was the indoor mobility item of the Spinal Cord Independence Measure (SCIM) taken upon discharge from rehabilitation. Univariate and multivariable models were created for each predictor, Odds Ratios (OR) were obtained by a multivariable logistic regression analysis, and Area Under the receiver operator Curve (AUC) was calculated for each model. Results We observed a significant correlation between the trauma variables and independent ambulation upon discharge from rehabilitation. Of the early variables, the Abbreviated Injury Scale for the spine region showed the strongest correlation. Conclusions These findings support using preliminary trauma variables for early prognostication of ambulation following a TSCI, allowing for tailored individual interventions.Level of Evidence: 3.

Introduction:Injury patterns are closely related to changes in behavior. Pandemics and measures undertaken against them may cause changes in behavior; therefore, changes in injury patterns during the coronavirus disease 2019 (COVID-19) outbreak can be expected when compared to the parallel period in previous years.Study Objective:The aim of this study was to compare injury-related hospitalization patterns during the overall national lockdown period with parallel periods of previous years.Methods:A retrospective study was completed of all patients hospitalized from March 15 through April 30, for years 2016-2020. Data were obtained from 21 hospitals included in the national trauma registry during the study years. Clinical, demographic, and circumstantial parameters were compared amongst the years of the study.Results:The overall volume of injured patients significantly decreased during the lockdown period of the COVID-19 outbreak, with the greatest decrease registered for road traffic collisions (RTCs). Patients’ sex and ethnic compositions did not change, but a smaller proportion of children were hospitalized during the outbreak. Many more injuries were sustained at home during the outbreak, with proportions of injuries in all other localities significantly decreased. Injuries sustained during the COVID-19 outbreak were more severe, specifically due to an increase in severe injuries in RTCs and falls. The proportion of intensive care unit (ICU) hospitalizations did not change, however more surgeries were performed; patients stayed less days in hospital.Conclusions:The lockdown period of the COVID-19 outbreak led to a significant decrease in number of patients hospitalized due to trauma as compared to parallel periods of previous years. Nevertheless, trauma remains a major health care concern even during periods of high-impact disease outbreaks, in particular due to increased proportion of severe injuries and surgeries.

Mass casualty incidents (MCIs) tax the available resources of the healthcare system and impact on the capacity to provide optimal treatment to all casualties. To assure an integrated care approach before, during and following MCIs, Israel maintains ongoing coordination and collaboration among the various stakeholders. Emergency preparedness consists of five main measures including national guidelines and standard operating procedures; training programs; ongoing monitoring systems; information systems; and, procurement of vital equipment and infrastructure. The response phase is based on five components including an automatic response; central control and coordination; connectivity between responders; collaboration between military and civilian entities; and coordinated risk communication. The post-response phase consists of learning lessons through After Action Reviews.

BackgroundEthnic disparities have been associated with injury and mortality. The impact of ethnicity on head and neck injury (HNI), traumatic brain injury (TBI), in-hospital mortality and resource utilization following a motorcycle crash (MCC) is undetermined. This study explored the influence of ethnicity in these aspects and the effect of helmet use on HNI and TBI following a MCC.MethodsThe National Trauma Registry provided hospitalization data on motorcycle riders and passengers between 2008 and 2017. Ethnicity was classified as Jews or Arabs, the two major ethnic groups in Israel. Univariate followed by multivariable logistic models were applied to examine ethnic disparities. Mediation effect was tested by structural equation modeling.ResultsAmong 6073 MCC casualties, Arabs had increased odds of HNI (OR = 1.37,95% CI = 1.12–1.65) and TBI (OR = 1.51,95%CI = 1.12–1.99), and a six-fold decreased odds of helmet use (OR = 0.16,95%CI = 0.12–0.22). The HNI and TBI associations with ethnicity were mediated by helmet use. Arabs had significantly higher odds for admission to intensive care unit (OR = 1.36,95%CI = 1.00–1.83), and lower odds for ambulance evacuation (OR = 0.73,95%CI = 0.61–0.89) and discharge to rehabilitation (OR = 0.55,95%CI = 0.39–0.7). In-hospital mortality was not associated with ethnicity.ConclusionsHelmet non-use is an important etiologic factor associated with motorcycle-related HNI and TBI among Arabs. While in Israel, ethnic equality exists in in-hospital health care, disparities in ambulance and rehabilitation utilization was found. Intervention programs should target the Arab population and focus on helmet compliance.

Background Road traffic collisions (RTC) are known to be one of the major causes of maxillofacial trauma (MFT). The road user factor is of crucial importance in the prevalence, severity and treatment of the maxillofacial injuries. The aim of the study was to determine the prevalence of maxillofacial trauma among road users as well as to illustrate injury patterns and identify road users at high risk. Methods This historical prospective multi-center study was based on Israel's Trauma Registry between 2008-2018, which included 4,829 hospitalized patients following RTC with MFT. Data were analyzed according to six road user types (vehicle driver, passenger, bicyclist, motorcyclist, pedestrian and e-bike/scooter), maxillofacial injury location and maxillofacial treatment. Results MFT, which accounts for 5% of the hospitalized RTC injuries, was not equally distributed among road users, as bicyclists and e-bike/scooters were more prone to maxillofacial trauma (7.2% and 10.1%, respectively) than vehicle drivers (3.2%). Children (age 0-14 years) comprised almost half of the cyclists, 25% of the pedestrians and 20% of the passengers. Some MFT patients experienced multiple injuries, with the majority involving jaw and facial bones and to a lesser extent the mouth, teeth, gingiva and alveolar bone (mouth and dento-alveolar (DA) trauma). Approximately 30% of hospitalized road casualties with MFT underwent MF surgery, with the need for surgery lowest among pedestrians. Conclusion Hospitalized road casualties had different types of MFT in terms of prevalence, location, severity and treatment, depending on the road user type. Appropriate preventive measures and the proper use of restraints are recommended to reduce maxillofacial injuries.

Background End-of-life decisions are highly complex socio-normative and ethical phenomena. The goal of this study was to provide an assessment of public opinions in Israel concerning aspects of end-of-life decisions. Methods An online cross sectional study was performed in February 2020. The primary tool including items pertaining to death assistance and truth telling to patients. A sample of 515 participants representative of the adult Israeli population was obtained. Results The majority of participants (71%) supports telling the entire truth to patients even in harsh conditions. Support for truth telling decreases with affiliation to religion, with as little as 40% support among ultra-orthodox. People with vocational education are the least supportive of truth telling. Concerning doctor assisted death, almost half (49%) of the sample were supportive. Opposition is positively associated with religiosity, with 90% of ultra-orthodox and 58% of religious participants opposing doctor-assisted death, compared to only 18% among seculars. Non-Jews were 3.35 times (95%CI: 1.90, 5.91) more likely to oppose doctor assisted death than Jews (p Conclusions Israelis are overwhelmingly supportive of truth telling to patients. In contrast, Israeli public opinions on doctor assisted death are divided. For both attitudes, religiousness plays a crucial role as a catalyst for conservatism and opposition to change. Almost a half of the public is also supportive of an autonomist approach that would allow patients to decide on ending their own lives.

BackgroundSelf-inflicted injury is a leading cause of death worldwide. It is hypothesized that due to instincts for self-preservation, the severity of abdominal injury would be decreased following suicidal self-stabbing in comparison to stab wounds from assault, and therefore a more conservative management might be considered.MethodsAll patients with isolated abdominal stab wound (SW) admitted to 19 Trauma Centers in Israel between the years 1997 and 2018 were included in the study. Patients with self-inflicted abdominal SW (Group I) were compared to victims with abdominal SW following assault (Group II).ResultsGroup I included 9.4% (314/3324) of patients eligible for this study. Compared to Group II, Group I patients were older (median: 39 years, IQR 28,52 vs. 24 years, IQR 19,33; p