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September 11 th events taught us, members of the medical community, that we need to prepared for the worst. Nuclear terror is no longer science fiction. Radiological weapons of mass terror come in three flavors: The first one is nuclear. Since 1992, there have been six known cases of highly enriched uranium or plutonium being intercepted by authorities as it passed in or out of the former Soviet Union. Constructing a nuclear fission weapon requires high-level expertise, substantial facilities, and lots of money. All three of which would be difficult, although not impossible, for a terrorist group to pull off without state support. However, terrorists could carry out potential mass destruction without sophisticated weaponry by targeting nuclear facilities using conventional bombs or hijacked aircrafts. Terror attacks could also carry out mass panic and radioactive contamination of people and environment by dispersal of radioactive materials with or without the use of conventional explosive devices. Most medical and para-medical personnel are not familiar with CBRN terror and radiation casualties. To lessen the impact of those potential attacks and provide care for the greatest number of potential survivors, the community as a whole - and the medical community in particular - must acquire the knowledge of the various signs and symptoms of exposure to irradiation and radioactive contamination as well as have a planned response once such an attack has occurred. Based on knowledge of radiation hazards, medical emergency planers should analyze the risks of each scenario, offer feasible solutions and translate them into internationally accepted plans that would be simple to carry out once such an attack took place. The planned response should be questioned and tested by drills. Those drills should check the triage, evacuation routes, decontamination posts, evacuation centers and receiving hospitals. It is crucial that the drill will consist of simulated casualties that will follow the evacuation route from point zero to the ED. Knowledge and exercise will reduce terror (fear) from radiation and help the community as a whole better cope with such an event. This article will review the general information of radiation types, their biological damage, clinical appearance and general concepts of nuclear event planning, focusing on medical response and focus on the Israeli perspective.

Introduction: The first cases of COVID-19 arrived in Israel in March 2020. In Israel, the first known cases were Israeli patients diagnosed with COVID-19 aboard the Diamond Princess which were repatriated. Shortly later, additional cases were found in increasing numbers constituting the "first wave". The high number of patients put significant strain on Israeli hospitals. The initial wave was later followed by additional surges in the number of patients further straining the system. At the peak, hospitals with a total bed capacity of 800 had 135 covid-19 patients with 21 of them requiring ventilatory support. Method: Daily and weekly multidisciplinary meetings were held and daily reports were composed. Following each wave, lessons learned and recommendations for improved preparedness were formulated. The following results and conclusion sections summarize some of the main insights and recommendations. Results: The main challenges in Beilinson hospital during the "first wave" were a shortage of personal protective equipment (PPE) and how to best utilize the existing supplies, uncertainty regarding infectiveness, best management practices and uncertainty regarding the expected magnitude and duration of the pandemic. In retrospect, the major insights were the need for a flexible and divisible ED to safely care for changing loads of suspected and verified COVID-19 patients as well as COVID-19 negative patients. Increasing the in-hospital stockpile of PPE as well as the regional and national stockpile and creating local production capacities. The importance of the daily multidisciplinary managerial meeting was to improve situational awareness and allow improved decision making. Staff briefing occurred on a daily basis and during times of high uncertainty at the beginning of every shift. Conclusion: Performing structured and frequent debriefing and analysis to achieve clinical and operational insights is crucial for improved short-term performance as well as improving preparedness for future challenges. [ABSTRACT FROM AUTHOR]

Introduction: The Emergency Department (ED) is the hospital's main gateway, as well as the initial site for diagnosis and emergency medical care. In recent years, ED overcrowding is worsening in Israel and world-wide. Overcrowding has been shown to adversely affect patient service and care, fostering patient and caregiver dissatisfaction, as well as lowering quality of care and even increasing mortality. A main driver of ED overcrowding is ED patient boarding due to limited inpatient bed availability in conjunction with hospital policy. Measuring median length of ED stay (LOS) for admitted vs. discharged patients can serve as a simple indicator for the severity of the access block over time and between facilities. Method: ED operational data from the computerized system of four hospitals in Israel were collected over a year and analyzed. In parallel data was collected regarding hospital capacity and ED volumes. Data were analyzed using SPSS. Results: The Mean ED LOS was significantly higher for ED patients needing admission in all hospitals. Mean ED LOS for admitted vs. discharged patients was 227 min vs.431 in hospital A, 215 min vs. 222 in hospital B, 198 min vs. 440 in hospital C and 167 min vs. 190 in hospital D. The discrepancy in LOS for admitted patients was not related to the total hospital bed capacity or the hospital ED patient volume. Conclusion: ED boarding is a major challenge for ED's and hospitals worldwide and a significant contributor to ED overcrowding. A tool to assess boarding is proposed. The tool calculates the ratio of median ED LOS between patients admitted to the hospital and those discharged. Slightly higher LOS among those admitted is to be expected, considering the fact that they usually present with more complex medical problems. In this study the LOS ratios were 1.03, 1.12, 1.90 and 2.22. [ABSTRACT FROM AUTHOR]

Introduction: Annually in the US, about 2 million patients who are animal-related casualties go to the Emergency Medicine Department (ER), which accounts for 0.5-1.5% of the ER visits; 25% of these casualties are children. Similar numbers are also seen in Europe and the UK. In a single-center study in Israel, it was found that the percentage of ER visits for animal injuries was about 2.1%. Soroka University Hospital is the only Level I trauma center in the Negev, serving a population of over 1,250,000, and as such it treats about 175,000 ER visits each year, of which about 27% are pediatric visits. The population treated in our hospital is diverse in terms of socioeconomic origin and status, and includes Jewish patients mainly situated in urban settlements and Arab-Bedouin population living in familiar and unfamiliar villages (the Bedouin diaspora). In light of this, in the present study, we have tried to investigate animal injuries in children, emphasizing scorpion bites which are common in our area., Methods: We retrospectively reviewed the medical records of all children aged 0-17 years during an 18-month study period - from January 2009 until the end of June 2010 - to identify children who have been referred to the ER at the Soroka Hospital due to animal injury. Demographics, characteristics of the injury, incidence times and referral to treatment, and data on the course of assessment and treatment of the injury and hospitalization were recorded. Data was typed and processed using Microsoft Excel 2007 software and we used SPSS 23.0 for Windows for the statistical analysis., Results: A total of 729 pediatric injuries caused by animals were reported, which accounted for about 1% of the total number of children's visits to the pediatric ER during the study period. Twenty-six cases were omitted because they did not meet the inclusion criteria in the study. Of the remaining 703 referrals, 66.1% of the patients were boys, the peak age was in the 6-8-year age group (26%); 44.1% lived in a Jewish settlement, 31.2% in an unrecognized Arab-Bedouin settlement and 24% in a recognized Arab-Bedouin settlement. In both forms of Bedouin settlements, the most frequent injuries were dog bites n = 166, (23.60%), yellow scorpion bites = 163 (23.2%) and black scorpion bites n = 44 (6.25%); 97 of the children were admitted (13.8%), of whom 44 were admitted to the ICU, with 84.1% of those admitted to the intensive care unit (ICU) were treated due to yellow scorpion injury. The 2-5-year age group was the most prevalent among inpatients, accounting for 32., Discussion: Pediatric animal injuries are a common cause of ER visits and even hospitalization. A relatively high percentage of hospitalizations were in the ICU. The most common cause of animal injury seen in our cohort was dog bites, but yellow scorpion bites resulted in most hospitalizations, especially in the pediatric ICU. The incidence of yellow scorpion injuries was significantly higher in the Arab-Bedouin population and even more so in those living in unrecognized settlements, and 87% of the pediatric hospitalizations were seen in Arabic-Bedouin children. Animal-related injuries are a serious health problem in the Arab-Bedouin population and in the unrecognized villages in particular, and there is room to emphasize the prevention of these injuries in this impoverished sector.

Objective: The aim of the study was to quantitatively measure the effect of teaching cardiopulmonary resuscitation (CPR) using a real-time audiovisual feedback manikin system on first-year medical student's CPR performance., Methods: This is a prospective, manikin-based intervention study, including 2 consecutive classes of medical school students enlisted to a mandatory first aid course. One class (control group) was taught using manikin-based standard CPR education models. The second class (intervention group) was taught similarly, but with the addition of real-time CPR quality feedback provided by the manikins. Students' performance was assessed using a standardized Objective Structured Clinical Examination scenario, during which no real-time feedback was provided. Critical CPR parameters were measured including compression depth, chest recoil, ventilation volume, and "hands-off" time., Results: A total of 201 participants were included in the study, 106 in the control group and 95 in the intervention group. Baseline demographic characteristics and previous medical knowledge were similar for the 2 groups. A significant improvement was observed for all primary study outcomes in favor of the real-time feedback group for median (interquartile range) chest compression fraction [57 (52.75%-60%) vs. 49 (43%-55%), P < 0.001], compressions with adequate depth [66.5 (19.5%-95.25%) vs. 0 (0%-12%), P < 0.001], ventilations with adequate volume [68.5 (33%-89%) vs. 37 (0%-70%), P < 0.00], and a simulator-derived composite "total CPR score" [39 (24%-61.25%) vs. 13 (3.5%-22%), P < 0.001]. In multiple regression analysis, the real-time feedback group's performance was significantly better than the control group in all primary outcomes, adjusting for participant's characteristics of age, sex, and body mass index., Conclusions: The use of audiovisual feedback techniques to teach CPR improves skill acquisition with significant improvement in crucial prognosis-improving parameters, as tested in a "no-feedback" test scenario.

Introduction: Mass-casualty incidents (MCIs) can occur outside of major metropolitan areas. In such circumstances, the nearest hospital seldom is a Level-1 Trauma Center. Moreover, emergency medical services (EMS) capabilities in such areas tend to be limited, which may compromise prehospital care and evacuation speed. The objective of this study was to extract lessons learned from the medical response to a terrorist event that occurred in the marketplace of a small Israeli town on 26 October 2005. The lessons pertain to the management of primary and secondary evacuation and the operational practices by the only hospital in the town, which is designated as a Level-2 Trauma Center., Methods: Data were collected during the event by Home Front Command Medical Department personnel. After the event, formal and informal debriefings were conducted with EMS personnel, the hospitals involved, and the Ministry of Health. The medical response components, interactions (mainly primary triage and secondary distribution), and the principal outcomes were analyzed. The event is described according to Disastrous Incidents Systematic Analysis Through Components, Interactions, Results (DISAST-CIR) methodology., Results: The suicide bomber and four victims died at the scene, and two severely injured patients later died in the hospital. A total of 58 wounded persons were evacuated, including eight severely injured, two moderately injured, and 48 mildly injured. Forty-nine of the wounded arrived to the nearby Hillel Yafe Hospital, including all eight of the severely injured victims, the two moderately injured, and 39 of the mildly injured. Most of the mildly injured victims were evacuated in private cars by bystanders. Five other area hospitals were alerted, three of which primarily received the mildly injured victims. Two distant, Level-1 Trauma Centers also were alerted; each received one severely injured patient from Hillel Yafe Hospital during the secondary distribution process. Emergency medical services personnel were able to treat and evacuate all severely and moderately injured patients within 17 minutes of the explosion. A total of 12 of the 21 ambulances arriving on-scene within the first 20 minutes were staffed by EMS volunteers or off-duty workers., Conclusion: When a MCI occurs in a small town that is in the vicinity of a Level-2 Trauma Center, and located a > 40 minute drive from Level-1 Trauma Centers, the Level-2 Trauma Center is a critical component in medical management of the event. All severely and moderately injured patients initially should be evacuated to the Level-2 Trauma Center, and given advanced, hospital-based resuscitation. The patients needing care beyond the capabilities of this facility should be distributed secondarily to Level-1 Trauma Centers. To alleviate the burden placed on the local hospital, some of the mildly injured victims can be evacuated primarily to more distant hospitals. The ability to control the flow of mildly injured patients is limited by the large percentage of them arriving by private cars. The availability of EMS in small towns can be augmented significantly by enrolling off-duty EMS workers and volunteers to the rescue effort. Level-2 hospitals in small towns should be prepared and drilled to operate in a "selective evacuation" mode during MCIs.

Background: Many emergency departments use coagulation studies in the evaluation of patients with suspected acute coronary syndromes., Objectives: To determine the prevalence of abnormal coagulation studies in ED patients evaluated for suspected ACS, and to investigate whether abnormal international normalized ratio/partial thromboplastin time testing resulted in changes in patient management and whether abnormal results could be predicted by history and physical examination., Methods: In this retrospective observational study, hospital and ED records were obtained for all patients with a diagnosis of ACS seen in the ED during a 3 month period. ED records were reviewed to identify patients in whom the cardiac laboratory panel was performed. Other data included demographics, diagnosis and disposition, historical risk factors for abnormalities of coagulation, ED and inpatient management, INR/PTT, platelet count and cardiac enzymes. Descriptive statistical analyses were performed., Results: Complete data were available for 223 of the 227 patients (98.7%). Of these, 175 (78.5%) were admitted. The mean age was 64.2 years. Thirteen patients (5.8%) were diagnosed with acute myocardial infarction. Of the 223 patients, 29 (13%) and 23 (10%) had INR and PTT results respectively beyond the reference range. Seventy percent of patients with abnormal coagulation test results had risk factors for coagulation disorders. The abnormal results of the remaining patients included only a mild elevation and therefore no change in management was initiated., Conclusions: Abnormal coagulation test results in patients presenting with suspected ACS are rare, they can usually be predicted by history, and they rarely affect management. Routine coagulation studies are not indicated in these patients.