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Israeli ED experience during the Gulf War
International
Notes
Israeli ED Experience During the Gulf War ZVI ROTENBERG,
MD, SHLOMO
NOY, MD URI GABBAY,
The experience in an emergency department (ED) during the Gulf War in treating casualties referred to the ED soon after each missile attack is reported. Data were gathered within an I)-hour period of each nationwide alert on all patients who presented to the ED with injuries or complaints directly related to the missile attacks of the Tel Aviv area. One hundred three patients presented with symptoms directly related to the missile attacks. Of 103, 70 suffered from acute psychological reaction, 19 from false autoinjection of atropine, and nine from physical injuries from the explosion. Of the remainder, four had mild symptoms of smoke inhalation, and one had intercurrent myocardial infarction. The missile attacks resulted in a relatively small number of serious injuries. Most of the patients who presented to the ED soon after the missile attacks suffered from either anxiety reaction or false atropin injection. (Am J Emerg Med 1994;12:118-119. Copyright 0 1994 by W.B. Saunders Company)
The Gulf War provided Israel with first-hand experience of missile attacks on a Western civilian population. From January 18 to February 28, 1991, in the course of 18 attacks, Iraq fired 39 ballistic missiles toward Israeli territory. Most were aimed at the densely populated, central coastal area of the country. Of the 39 missiles, only six caused direct casualties among the civilian population of Tel Aviv and its environs. The Iraqi medium-range, surface-to-surface ballistic missiles (SSBM) are a modified version of the Soviet Scud-B SSBM. To increase the range of these missiles, the weight of the warhead was reduced to 300 kg instead of 1 ton, and the booster motor was improved. Because of the threat that missiles armed with nonconventional warheads might be fired, civil defense authorities distributed personal protection equipment (gas masks for all age groups and atropine autoinjections). Each household was instructed to prepare a specially sealed room for use in the event of missile attacks. Beilinson Medical Center is an 820-bed hospital located in the center of Israel, near Tel Aviv. The aim of our study was to report our experience in the emergency department (ED) during the Gulf War in treating all casualties who were referred to us soon after the missile attacks. From the Emergency Department, Beilinson Medical Center, Petah Tiqva, Sackler Faculty of Medicine, Tel Aviv University, Israel. Manuscript received April 2, 1993; accepted April 3, 1993. Presented in part at the Fourth International Conference on Emergency Medicine, Washington DC, May 1992. Address reprint requests to Dr Rotenberg, Director, Emergency Department, Beilinson Medical Center, Petah Tiqva 49100, Israel. Key Words: Disaster medicine. Copyright 0 1994 by W.B. Saunders Company 0735-6757/94/l 201-0031$5.00/O 118
MD
MATERIALSAND METHODS Because the areas hit by the missiles were in close proximity to large hospitals, all casualties arrived within a short time (up to 30 minutes) of the attack, regardless of the severity of the injury. We systematically gathered the data on all these admitted to our ED within 8 hours after each nationwide alert. More information was then collected on the type of injuries. Our study population included only patients with injuries or complaints directly related to the missile attacks.
RESULTS During the Gulf War, 103 patients were admitted to the ED with symptoms directly related to the missile attacks on the Tel Aviv area (Table 1). Seventy were admitted in a state of acute psychological distress; one third presented during the first days of the attacks, most (60%) of whom were women (mean age, 38 years). The somatic symptoms of these patients included chest pain (20%), headache (20%), dyspnea (IO%), and diffuse symptoms (50%). Only a minority (16%) had a mental history. All were treated in a special center for psychological stress reactions and were discharged after 1 to 3 hours. Nineteen patients were admitted because of unjustified autoinjection of atropine (false injection). All presented with mild anticholinergic symptoms and were discharged after a few hours. Most were admitted during the first days of the was. Nine patients were directly injured from the explosion of the missiles: six were classified as moderately injured, most with orthopedic injuries and had to be hospitalized. Three suffered mild injuries from glass shards, projectiles, or building fragments. Four additional patients had mild symptoms of smoke inhalation, and one patient died of intercurrent myocardial infarction. DISCUSSION Comparison of the distribution of injuries in the present study with that of the total 1,060 casualties reported by all EDs in Israel during the Gulf War’ shows similar findings. Of the 1,060 patients, one half (544) suffered from acute anxiety, 230 from false atropine injection, and only 234 from injuries directly related to the explosions, of which only one was severe. Another 40 patients suffered injuries while rushing to the sealed room or shelter. Eleven deaths were reported; seven by suffocation caused by gas masks in which filters were left closed and four by intercurrent myocardial infarction. Our most striking finding is the relatively small number of direct injuries from the explosions. The following factors may explain this result: (1) the building technique used in
ROTENBERG
TABLE
1.
ET AL H DISASTER
Type of Injuries
119
MEDICINE
Directly
Related
to Missile Attacks No of Casualties 70 19 9 6 3 4 1
Acute psychological distress False atropine injections Direct injuries Moderate Mild Smoke inhalation Intercurrent death
103
Total
rapid discharge from the hospital. All 70 patients who suffered from acute psychological distress were treated in such a center and were discharged after a few hours. The two major reasons for presentation, acute anxiety and false atropine auto-injections, could be the result of the process of preparing the civilian population for a possible attack by chemical warfare. Most patients presenting for these reasons did so in the first days of the war. As public knowledge increased, we saw a considerable reduction in the level of anxiety as well as in the number of false injections. CONCLUSIONS
these areas (steel structure),
which
prevented
collapse
of the
under ruins; (2) the relatively small size of the warhead and supersonic speed of the missile (so that there was no blast wave); (3) the adherence of the public to the recommendations of the army to remain inside the sealed rooms or shelters during the attacks; and (4) the migration of part of the population of the target areas to other parts of the country. There is no doubt that the Gulf War and the missile attacks caused extensive long-term stress in large segments of the Israeli population.’ Experience shows that despite the principle that stress casualties should not be evacuated to the hospital,3 they are usually brought in anyway. Therefore, hospitals should have a special center for psychological stress reactions4 in which experienced teams administer stress reaction therapy. Proper intervention should lead to buildings
and the trapping
or crushing
of victims
Iraqi missile attacks against Israel during the Gulf War resulted in a relatively small number of serious injuries and fatal casualties. Most of the patients who presented to our ED soon after the missile attacks suffered from either acute anxiety reactions or false injections of atropine. REFERENCES 1. Karsenty E, Shemer J. Alshech I, et al: Medical aspects of the Iraqi missile attacks on Israel. Isr J Med Sci 1991;27:603-607 2. Bleich A, Kron S, Margalit C, et al: Israeli psychological casualties of the Persian Gulf war: Characteristics, therapy, and selected issues. Isr J Med Sci 1991;27:673-676 3. Solomon 2, Garb R, Bleich A, et al: Reactivation of combat related PTSD. Am J Psychiatry 1987;144:51-55 4. Shoham S, Bleich A: Psychological injuries in mass casualty events: Treatment principles at the hospital level. ISD Med Corps J 1990;32:57-59
Notes
Israeli ED Experience During the Gulf War ZVI ROTENBERG,
MD, SHLOMO
NOY, MD URI GABBAY,
The experience in an emergency department (ED) during the Gulf War in treating casualties referred to the ED soon after each missile attack is reported. Data were gathered within an I)-hour period of each nationwide alert on all patients who presented to the ED with injuries or complaints directly related to the missile attacks of the Tel Aviv area. One hundred three patients presented with symptoms directly related to the missile attacks. Of 103, 70 suffered from acute psychological reaction, 19 from false autoinjection of atropine, and nine from physical injuries from the explosion. Of the remainder, four had mild symptoms of smoke inhalation, and one had intercurrent myocardial infarction. The missile attacks resulted in a relatively small number of serious injuries. Most of the patients who presented to the ED soon after the missile attacks suffered from either anxiety reaction or false atropin injection. (Am J Emerg Med 1994;12:118-119. Copyright 0 1994 by W.B. Saunders Company)
The Gulf War provided Israel with first-hand experience of missile attacks on a Western civilian population. From January 18 to February 28, 1991, in the course of 18 attacks, Iraq fired 39 ballistic missiles toward Israeli territory. Most were aimed at the densely populated, central coastal area of the country. Of the 39 missiles, only six caused direct casualties among the civilian population of Tel Aviv and its environs. The Iraqi medium-range, surface-to-surface ballistic missiles (SSBM) are a modified version of the Soviet Scud-B SSBM. To increase the range of these missiles, the weight of the warhead was reduced to 300 kg instead of 1 ton, and the booster motor was improved. Because of the threat that missiles armed with nonconventional warheads might be fired, civil defense authorities distributed personal protection equipment (gas masks for all age groups and atropine autoinjections). Each household was instructed to prepare a specially sealed room for use in the event of missile attacks. Beilinson Medical Center is an 820-bed hospital located in the center of Israel, near Tel Aviv. The aim of our study was to report our experience in the emergency department (ED) during the Gulf War in treating all casualties who were referred to us soon after the missile attacks. From the Emergency Department, Beilinson Medical Center, Petah Tiqva, Sackler Faculty of Medicine, Tel Aviv University, Israel. Manuscript received April 2, 1993; accepted April 3, 1993. Presented in part at the Fourth International Conference on Emergency Medicine, Washington DC, May 1992. Address reprint requests to Dr Rotenberg, Director, Emergency Department, Beilinson Medical Center, Petah Tiqva 49100, Israel. Key Words: Disaster medicine. Copyright 0 1994 by W.B. Saunders Company 0735-6757/94/l 201-0031$5.00/O 118
MD
MATERIALSAND METHODS Because the areas hit by the missiles were in close proximity to large hospitals, all casualties arrived within a short time (up to 30 minutes) of the attack, regardless of the severity of the injury. We systematically gathered the data on all these admitted to our ED within 8 hours after each nationwide alert. More information was then collected on the type of injuries. Our study population included only patients with injuries or complaints directly related to the missile attacks.
RESULTS During the Gulf War, 103 patients were admitted to the ED with symptoms directly related to the missile attacks on the Tel Aviv area (Table 1). Seventy were admitted in a state of acute psychological distress; one third presented during the first days of the attacks, most (60%) of whom were women (mean age, 38 years). The somatic symptoms of these patients included chest pain (20%), headache (20%), dyspnea (IO%), and diffuse symptoms (50%). Only a minority (16%) had a mental history. All were treated in a special center for psychological stress reactions and were discharged after 1 to 3 hours. Nineteen patients were admitted because of unjustified autoinjection of atropine (false injection). All presented with mild anticholinergic symptoms and were discharged after a few hours. Most were admitted during the first days of the was. Nine patients were directly injured from the explosion of the missiles: six were classified as moderately injured, most with orthopedic injuries and had to be hospitalized. Three suffered mild injuries from glass shards, projectiles, or building fragments. Four additional patients had mild symptoms of smoke inhalation, and one patient died of intercurrent myocardial infarction. DISCUSSION Comparison of the distribution of injuries in the present study with that of the total 1,060 casualties reported by all EDs in Israel during the Gulf War’ shows similar findings. Of the 1,060 patients, one half (544) suffered from acute anxiety, 230 from false atropine injection, and only 234 from injuries directly related to the explosions, of which only one was severe. Another 40 patients suffered injuries while rushing to the sealed room or shelter. Eleven deaths were reported; seven by suffocation caused by gas masks in which filters were left closed and four by intercurrent myocardial infarction. Our most striking finding is the relatively small number of direct injuries from the explosions. The following factors may explain this result: (1) the building technique used in
ROTENBERG
TABLE
1.
ET AL H DISASTER
Type of Injuries
119
MEDICINE
Directly
Related
to Missile Attacks No of Casualties 70 19 9 6 3 4 1
Acute psychological distress False atropine injections Direct injuries Moderate Mild Smoke inhalation Intercurrent death
103
Total
rapid discharge from the hospital. All 70 patients who suffered from acute psychological distress were treated in such a center and were discharged after a few hours. The two major reasons for presentation, acute anxiety and false atropine auto-injections, could be the result of the process of preparing the civilian population for a possible attack by chemical warfare. Most patients presenting for these reasons did so in the first days of the war. As public knowledge increased, we saw a considerable reduction in the level of anxiety as well as in the number of false injections. CONCLUSIONS
these areas (steel structure),
which
prevented
collapse
of the
under ruins; (2) the relatively small size of the warhead and supersonic speed of the missile (so that there was no blast wave); (3) the adherence of the public to the recommendations of the army to remain inside the sealed rooms or shelters during the attacks; and (4) the migration of part of the population of the target areas to other parts of the country. There is no doubt that the Gulf War and the missile attacks caused extensive long-term stress in large segments of the Israeli population.’ Experience shows that despite the principle that stress casualties should not be evacuated to the hospital,3 they are usually brought in anyway. Therefore, hospitals should have a special center for psychological stress reactions4 in which experienced teams administer stress reaction therapy. Proper intervention should lead to buildings
and the trapping
or crushing
of victims
Iraqi missile attacks against Israel during the Gulf War resulted in a relatively small number of serious injuries and fatal casualties. Most of the patients who presented to our ED soon after the missile attacks suffered from either acute anxiety reactions or false injections of atropine. REFERENCES 1. Karsenty E, Shemer J. Alshech I, et al: Medical aspects of the Iraqi missile attacks on Israel. Isr J Med Sci 1991;27:603-607 2. Bleich A, Kron S, Margalit C, et al: Israeli psychological casualties of the Persian Gulf war: Characteristics, therapy, and selected issues. Isr J Med Sci 1991;27:673-676 3. Solomon 2, Garb R, Bleich A, et al: Reactivation of combat related PTSD. Am J Psychiatry 1987;144:51-55 4. Shoham S, Bleich A: Psychological injuries in mass casualty events: Treatment principles at the hospital level. ISD Med Corps J 1990;32:57-59