To the Editor:—

At 2:12 pm on Saturday, October 4, 2003, while sitting in a car wash in Haifa with my wife, I heard the explosion. I turned and saw a thick black pillar of smoke. It was a blast detonated by a suicide bomber.

My first thought as an attending anesthesiologist at the Jerusalem Hadassah-Hebrew University Medical Center was, “This shouldn’t be happening! I’m not in Jerusalem.”

I grabbed my first aid kit and instructed my wife to stay put. Then I sprinted the 100 ft separating me from the bombed restaurant. As I was running, I was dialing the equivalent of 911 on my mobile phone. In the midst of all this anxiety, I was trying to describe my location. Although I thought I was being factual and coherent, they kept asking me, “What is the name of the restaurant?” I simply didn’t know. Suddenly I noticed a sign on the building giving me the exact name of the restaurant.

The restaurant was quiet when I reached it. I saw a scene of total devastation. There was total silence: no crying, no screaming, no groaning, a paradoxical transient calmness. Glass and rubble crunched under my feet. Anyone who was able had fled from the scene. Those who were unable to flee lay silently on the floor. The interior of the restaurant was flattened—a miniature “Ground Zero.” Exposed electric wires sparked, water poured out of destroyed piping. Pieces of wood and masonry crumbled and fell. Among all this destruction lay dozens of people who were seriously hurt and many unfortunately already dead.

I have worked at the Hadassah’s emergency department after some 40 terror attacks over the past 3 yr. I was with my young daughter, yards away from a pizzeria in downtown Jerusalem, when a suicide bomber destroyed it in August 2001. But the nature of the destruction I witnessed after the attack on Haifa’s Maxim Restaurant was of an entirely different magnitude. There was a sense of total desecration of human life. My emotions were distorted. I walked around with a feeling of dread. The visions of destruction included jumbles of human bodies lying in nonphysiologic postures, puddles of blood, extensive third-degree burns, distorting maxillofacial injuries, open wounds exposing internal organs (mainly brains), and a decapitated head.

I did not know what to do. Should I choose one survivor, giving him or her the best treatment I could, and abandon the others? My first aid kit seemed ridiculous among the multiple casualties. I quickly decided that my trauma skills could best be utilized by performing a preliminary triage. As I moved from one body to another, I checked for signs of life (size and reactivity of pupils, central pulse and respiratory efforts). I labeled as dead anybody that lacked all  these criteria. For those who had signs of life, I performed a shortened primary evaluation (“A + B + half C,” patency of airway, symmetry of chest rising/air entrance and major external bleeding). When I had completed this initial triage, there was still no ambulance at the scene. Outside, I saw a crowd in the distance. They did not disturb, nor did they help. Only two or three people remained with me inside the restaurant. I tried to use these individuals to evacuate two survivors, but they were stunned and would not cooperate. Seeing I had no help, I then focused on the one survivor that I believed had an excellent chance of survival. She was responsive to pain and snoring because of maxillofacial burns and fractures. I asked for help from these remaining people in the restaurant to pull away two bodies so I could get free access to her face. They just stared at me. I tried to intubate her but failed because she was semiconscious and resisting, and the airway was full of blood. Then, to my relief, exactly when I raised my head looking for help, I saw the first paramedic enter. It seemed like an eternity until they arrived, but in fact, it was only 10 min.

The crews ran into the wreckage with stretchers, ventilators, infusions, and other equipment. I introduced my self by name and profession. Some of them were so shocked by the scene I had to shout at them to get their cooperation. Then, I directed these first-line emergency helpers away from the dead. However, some of the patients I had seen at the time of my initial triage were now dead.

When further manpower and equipment arrived, I started resuscitation procedures as we do in the emergency department in a multiple-casualty situation: I went back with a paramedic to the patient who I had failed to intubate earlier. Together, we were able to intubate her, and I gave the paramedic instructions on how to continue therapy. Then, I moved on to intubate the next survivor, leaving him with another paramedic. After this, I went back to see how the first paramedic was doing, and moved to a third survivor with severe head injury. After this intubation, I went back to check as to how the first and second were doing.

Then, I helped to load the stretchers onto the ambulances with the help of policemen and fire fighters. Nonprofessional help was available only from the firemen and police because all the other people were frozen with fear. I too was emotionally numb, unaware of feelings, sounds, or smells. A shard of glass cut my elbow, but this remained unnoticed for 3 h.

It was 25 min after the explosion when I rode in the ambulance with the third patient I had treated. We exposed the whole body for assessment and obtained venous access on the way to the nearest hospital. The hospital’s emergency department was already overwhelmed when we arrived. Nurses helped me to locate medical instruments and supplies, inserting an additional large bore intravenous catheter, sending blood tubes to laboratories, measuring vital signs, and arranging for x-rays and ultrasound, until a local physician was free and took over.

My wife met me outside the hospital and we drove home. On the way, I was thinking about the decision I made after running to help inside the first pizzeria bombing in Jerusalem and how dangerous it was. Wouldn’t anyone with a healthy sense of self-preservation run in the opposite direction? Now it had happened to me again, and all rational thinking disappeared. I ran to the restaurant and acted on a professional instinct, and I do not regret that.

The next day, I went to work, a hundred miles away. There was no way I could really share this experience because I (wrongly) believed it was inappropriate to describe the sights in detail. The next three nights, I woke every half hour, thinking of what I did in the wreckage, how I could have done things better. Sights and even smells of the violently desecrated bodies flashed into my mind constantly. It was as if all the emotions suppressed in the restaurant had been stored in memory, and I was now unzipping the file. It was difficult admitting that I was taking it so hard. I have seen trauma patients since I was a 16-yr-old volunteer with the emergency medical service in Jerusalem. As an anesthesiologist, I have specialized in trauma anesthesia. I teach trauma care. I am soon to spend a year in Miami’s Ryder Trauma center (Jackson Memorial Hospital), further specializing in the field. But I could not free myself.

I realized I should share my first-hand experience and personal conclusions from these two events with non–emergency medical service first responders. I hope that knowing what to expect will help others in case they find themselves in a similar situation:

  1. Call for help (911).

  2. If you are accompanied by a non-medical professional (e.g., family), make sure they stay in a safe place, out of view.

  3. Be ready for sights unfamiliar in the emergency department. Anticipate the normal state of shock and helplessness so you can fight it.

  4. Until the emergency medical service arrives, you are in a real mass-casualty event . The best thing to do is start triaging. Identify the dead (reactivity and size of pupils, central pulse, and respiratory efforts). Perform a short primary survey of the survivors (A, B, and half C).

  5. After the emergency medical service arrives, it is the simpler multiple-casualty event  scenario. Introduce yourself repeatedly by name and medical profession; give your triage information to the first paramedic, and only then start treating survivors.

  6. If you are asked to step out, obey.

  7. The environment is dangerous: The broken glass and metal shards are a real hazard, as well as the danger of a collapsing ceiling. More important is the danger of a second explosion resulting from a combination of exposed electric wires, perforated water, and gas pipes, as well as a second bomb scheduled to hurt the rescuers. Quick evacuation of survivors is therefore mandatory, thus enabling firemen and bomb squads to prevent further injuries. I believe that clearing the scene to protect survivors and rescuers justifies compromise of meticulous spinal cord immobilization.

  8. In an urban area with the existence of many evacuating vehicles, only a limited number of interventions are indicated on scene: airway secure, tension pneumothorax relief, major external bleeding control, and spine immobilization. All other things can be done en route .

  9. Do not hesitate to seek early psychological consultation to prevent chronic posttraumatic stress disorder.

The author thanks Wendy Elliman, B.A. (Jerusalem, Israel), and Michael C. Lewis, M.D. (Associate Professor, Anesthesiology, University of Miami School of Medicine, Miami, Florida), who helped with converting a difficult experience to words.