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Foreign Exchange Caspi displays protective gear used by MDA responders. ranking personnel, and scenes can be divided into sectors. between EMS and police and fi re, and the roles that each play.” On scenes, seconds count. The biggest difference between American and Israeli prehospital operations is the latter’s emphasis on quick triage, clearing and resolution of even large and complex scenes. There’s no staging, no lengthy assessment or decon processes—just a precisely choreographed “scoop and play” designed to get patients stabilized and gone. “ This is not only due to possible secondary devices, but because Jewish law requires collection of all body fragments for burial before they’re lost or destroyed (challenging in some bomb attacks) and because Israel puts a premium on a fast return to normalcy—denying terrorists the victory of disruption. During the normal. That’s part of the resiliency. Like the MDA folks said, ‘You killed some of us, but you didn’t stop us.’ That’s the mind-set.” Suicide Bombers Suicide bombers represent a unique and lethal threat that really has not yet made its way to the U.S. In Israel their attacks are rare but deadly: Between September 29, 2000, and December 29, 2007, they accounted for just 155 of 30,595 tallied attacks—half of one percent— but 525 of those attacks’ 1,065 resulting deaths, or 49%. The suicide bomber is in effect a human smart bomb that can choose the time and place of its own detonation. From 2002–05, MDA averaged a 4.6-minute fi rst-ambulance response to suicide bombings, and 11.5 minutes to fi rst evacuation. Keeping You killed some of us, but you didn’t stop us.” March Jerusalem bus stop bombing, the fi rst patient was removed nine minutes after the fi rst call for help. “It’s a completely different approach than we teach here,” says Wingrove, “where we wait to secure the scene before any EMS personnel go in.” “A lot of our response is about triage, setting up all this stuff, controlling the scene, getting transportation and all of these things there,” adds DeTienne. “They really emphasize, not just with EMS but for all the responders, clearing the scene quickly and getting back to 10 JULY 2011 EMS WORLD things moving requires keeping things simple. Crews arrive at scenes and deliver primary reports, then establish medical command, conduct triage and immediate lifesaving procedures, and then load and get going as quickly as further resources permit. Regional dispatch, upon identifying a scenario, activates its relevant protocol/checklist, notifi es hospitals and ensures appropriate distribution of casu- alties. As more responders arrive, an overall incident commander is named (police always in charge), EMS command shifts to higher- Reinforcements at major-incident scenes come not only from fi rst responders and volun- teers, but from off-duty crews (some keep ambulances at their homes) and regional mutual aid. Bystanders are also frequently incorporated under the theory that it’s better to utilize them than combat them. Common injuries in suicide bombing events include blast and burn injuries and blunt and penetrating trauma. Initial triage is focused only on immediate life threats—“the reds and the rest.” Lifesaving procedures performed on scene, needed by only 3%–5% of casualties, include airway control/intubation and hemor- rhage control. Fluids and additional care are given en route. Other measures help keep up the pace. No one marks sectors; instead they use landmarks to identify them. There’s no scene decontami- nation; patients are deconned at the ED. After events, crews undergo medical and operational debriefi ngs where they examine what went right, what went wrong, and what else they could do on such scenes. Critical incident stress debriefi ng is also offered. The U.S. Perspective Those versed in ICS and U.S. major incident scenes will fi nd much of the Israeli response structure familiar. Details differ, though, starting with the emphasis on speed. “Most of our mass- casualty scenes are crime scenes and can last for hours,” says Stein-Spencer. “We truly don’t get back to normal as quickly as we should.” “For us it’s a lot more circumstance-driven,” adds Charles Stewart, fi rst deputy fi re commis- sioner for the Chicago Fire Department. “We also work to clear the scene and get in and get out as quickly as possible, but it depends on the circumstances. I think there’s a message to it [with the Israelis]: ‘We’re not being consumed by these attacks. We’re getting back to normal as quickly as possible.’” Many of the U.S. delegation expressed an interest in working to expedite their own systems’ scene times. “Here in Montana, with our extremes in weather, we really shouldn’t be on scenes too