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Foreign Exchange regimen of training. Since 2010 in particular, exercises have been larger and more consistent, with an increased medical focus and synchronized medical and nonmedical aspects. Each hospital in Israel drills regularly on areas planned in advance and rotated (e.g., a chemical event one month, an earthquake the next). This is not required by law, but a result of cooperation between hospitals. Medical staff must also well understand the pathologies of the threats they face—with bombings, for instance, burn and blast injuries and blunt and penetrating trauma. Suicide bombers in Israel have frequently packed their explosives with ball bearings, metal fragments, pellets and other shrapnel designed to maim. Other threats have their own considerations. Medically, staff have to be ready to move quickly: A 2006 review of suicide bomb attacks found the fi rst admitted patient with ISS greater than 16 typically arrived 5 minutes from time zero, and 35% of the injured arrived in the fi rst 10 minutes. In many major events, patients will be arriving even as hospitals are preparing to receive them. This necessitates fast activation of plans and personnel. Surges also require close cooperation with EMS. When an event happens, prehospital responders provide prompt notifi cation of the time, location and mechanism of the event and the number of injured. EMS hospital liaisons track patient fl ow and help ensure equitable casualty distribution, while funneling information from the fi eld to ED staffs and back. Rambam is also prepared for surges with a shock trauma room that can expand with spaces between beds, and extra equipment and supplies stored on portable carts for fast bedside access. In the Lebanon war, hospital leaders devised a new method of one-way patient fl ow: Patients who left the ED didn’t come back. Those without physical injury were sent to an anxiety site, and the mildly hurt were segregated into a separate location for delayed treatment. That let ED teams focus on the moderately and severely Plenty of spaces between beds allows room for extra trauma patients during surges. injured. These were eventually dispatched to OR, ICU, imaging, wards or home, with a site set up in imaging to hold patients there for later disposition. “ At the management level, software helped track clinical and administrative needs and We have options like that everywhere, and just never thought about them.” keep leaders apprised of patient volumes, injury types and severity in the ED and hospital. The injured were recorded in the ADAM program, a nationwide casualty identifi cation system. ADAM interfaces online with hospitals’ patient registration systems, letting them transfer data electronically, and provides information to other hospitals, police, the Ministry of Health and others on casualties both identifi ed and unidentifi ed. Unidentifi ed victims are photo- graphed and their pictures included to facilitate identifi cation. Worried loved ones can go to any hospital in the country to search the system. In military confl icts there are anxiety reac- tions to consider as well. The Lebanon war accounted for around 2,700 Israeli stress reac- tions. When something big happens, psycho- logical staff and social workers are activated along with clinical staff. So is daycare—the Israelis have found having a safe care option for their kids greatly infl uences whether workers will report in an emergency. For providers, mental healthcare begins immediately and brings together ED, medical and logistical staff, plus MDA in a formal, stan- dardized debriefi ng process. The U.S. Perspective The underground garage/hospital is a cool and novel thing—“We have options like that everywhere, and just never thought about them,” notes Wingrove. But even the most advanced security measures aren’t what ulti- mately distinguishes Rambam and other top Israeli trauma centers (such as Jerusalem’s Hadassah University Hospital-Ein Kerem, with EMS WORLD JULY 2011 13