Terrorist suicide bombings: Lessons learned in Metropolitan Haifa from September 2000 to January 2006


  • Michal Mekel, MD
  • Amir Bumenfeld, MD
  • Zvi Feigenberg, MD
  • Daniel Ben-Dov, MD
  • Michael Kafka, MD
  • Oren Barzel, MD
  • Moshe Michaelson, MD
  • Michael M. Krausz, MD




suicide bombing, terrorist attcks, multi casualty incidents


Background: The threat of suicide bombing attacks has become a worldwide problem. This special type of multiple casualty incidents (MCI) seriously challenges the most experienced medical facilities.
Methods: The authors concluded a retrospective analysis of the medical management of victims from the six suicide bombing attacks that occurred in Metropolitan Haifa from 2000 to 2006.
Results: The six terrorist suicide bombing attacks resulted in 411 victims with 69 dead (16.8 percent) and 342 injured. Of the 342 injured, there were 31 (9.1 percent) severely injured, seven (2.4 percent) moderately severely injured, and 304 (88.9 percent) mildly injured patients.
Twenty four (77 percent) of the 31 severely injured victims were evacuated to the level I trauma center at Rambam Medical Center (RMC). Of the seven severely injured victims who were evacuated to the level II trauma centers (Bnai-Zion Medical Center and Carmel Medical Center) because of proximity to the detonation site, three were secondarily transferred to RMC after initial resuscitation. Eight of the 24 severely injured casualties, admitted to RMC, eventually died of their wounds.There was no in-hospital mortality in the level II trauma centers.
Conclusions: A predetermined metropolitan triage system which directs trauma victims of a MCI to the appropriate medical center and prevents overcrowding of the level I facility with less severe injured patients will assure that critically injured patients of a suicide bombing attack will receive a level of care that is comparable with the care given to similar patients under normal circumstances. Severe blast injury victims without penetrating injuries but with significant pulmonary damage can be effectively managed in ICUs of level II trauma centers.

Author Biographies

Michal Mekel, MD

Rambam Medical Center (RMC), Israel Institute of Technology, Haifa, Israel; Technion, Israel Institute of Technology, Haifa, Israel.

Amir Bumenfeld, MD

Trauma Branch, Israel Defense Forces (IDF) Medical Corps, Haifa, Israel.

Zvi Feigenberg, MD

Magen David Adom (MDA) Israeli National Emergency Medical Services, Haifa, Israel.

Daniel Ben-Dov, MD

Carmel Medical Center (CMC), Haifa, Israel.

Michael Kafka, MD

Bnai-Zion Medical Center (BZMC), Haifa, Israel.

Oren Barzel, MD

Rambam Medical Center (RMC), Israel Institute of Technology, Haifa, Israel; Technion, Israel Institute of Technology, Haifa, Israel.

Moshe Michaelson, MD

Rambam Medical Center (RMC), Israel Institute of Technology, Haifa, Israel; Technion, Israel Institute of Technology, Haifa, Israel.

Michael M. Krausz, MD

Rambam Medical Center (RMC), Israel Institute of Technology, Haifa, Israel; Technion, Israel Institute of Technology, Haifa, Israel.


Slater MS, Trunkey DD: Terrorism in America: An evolving threat. Arch Surg. 1997; 132: 1059-1066.

Stein M, Hirshberg A: Medical consequences of terrorism: The conventional weapon threat. Surg Clin North Am. 1999; 79: 1537-1552.

Frykberg ER: Principles of mass casualty management following terrorist disasters. Ann Surg. 2004; 239: 319-321.

Mallonee S, Shariate S, Stenniies G, et al.: Physical injuries and fatalities resulting from Oklahoma City bombing. JAMA. 1996; 276: 382-387.

Gutierrez de Caballos JP, Turegano-fuentes F,Perez Diez P, et al.: 11 March 2004: The terrorist bomb explosions in Madrid, Spain—An analysis of the logistics, injuries sustained and clinical management of casualties treated at the closest hospital. Crit Care. 2005; 9: 104-111.

Rudoplu U, Arnold JL, Tokyay R, et al.: Mass casualty terrorist bombings in Istanbul, Turkey, November 2003: A report of the events and prehospital response Prehosp Disast Med. 2004; 2: 133-145.

Rian J, Montgomery H: Terrorism and the medical response. N Engl J Med. 2005; 353: 543-545.

Minz Y, Shapira SC, Pikarsky A, et al.: The experience of one institution dealing with terror: the El Aqsa intifada riots. Isr Med Ass J. 2002; 4: 554-556.

Israel Defense Forces. Available at www.idf.il/dover/site/ mainpage.asp. Accessed January 7, 2006.

The National Association of Emergency Medical Technicians and the American College of Surgeons Committee on Trauma: Introduction. In McSwaine N, Salomone J, (eds.): PHTLS: Basic and Advanced Prehospital Trauma Life Support, 5th ed. St Louis: Mosby, 2003.

Krueger AB, Maleckova J: Education, poverty and terrorism: Is there a causal connection? J Econ Perspect. 2003; 17: 119-144.

Katz E, Ofek B, Adler J, et al.: Primary blast injury after a bomb explosion in a civilian bus. Ann Surg. 1989; 209: 484-488.

Leibovici D, Gofrit ON, Stein M, et al.: Blast injuries in a bus versus open air bombings: A comparative study of injuries in survivors of open air vesus confined space explosions. J Trauma. 1966; 41: 1030-1035.

Wightman JM, Gadish SL: Explosions and blast injuries. Ann Emerg Med. 2001; 37: 664-678.

DePalma RG, Burris DG, Champion HR, et al.: Blast injuries. N Engl J Med. 2005; 352: 1335-1342.

Almogy G, Luria T, Richter E, et al.: Can external signs of trauma guide management? Lessons learned from suicide bombings attacks in Israel. Arch Surg. 2005; 140: 390-393.

Pesola GR, Dujar A, Wilson S: Emergency preparedness: The World Trade Center and Singapore Airline disasters. Acad Emerg Med. 2002; 9: 220-222.

American College of Surgeons, Committee on Trauma: Resources for Optimal Care of the Injured Patient. Chicago: American College of Surgeons, 1999.

Einav S, Feigenberg Z,Weissman C, et al.: Evacuation priorities in mass casualty terror related events: Implications for contingency planning. Ann Surg. 2004; 239: 304-310.

Klein JS,Weigelt JA: Disaster management: Lessons learned. Surg Clin North Am. 1991; 71: 257-266.

Trunkey DD: History and development of trauma care in the United States. Clin Orthop Relat Res. 2000; 374: 36-46.

Peitzman AB, Courcoulas AP, Stinson C, et al.: Trauma center maturation. Quantification of process and outcome. Ann Surg. 1999; 230: 87-94.

Spira RM, Reissman P, Goldberg S, et al.: Evacuation of trauma patients solely to level I trauma centers: Is the question patient or trauma center survival? Isr Med Ass J. 2006; 8: 129-130.

Peleg K, Aharonson-daniel L, Stein M, et al.: Increased survival among severe trauma patients: The impact of a national trauma system. Arch Surg. 2004; 139: 1231-1236.

Demitriades D: The effect of trauma center designation and trauma volume on outcome in specific severe injuries. Ann Surg. 2005; 242: 512-517.

Hirshberg A, Stein M,Walden R: Surgical resource utilization in urban terrorist bombing: A computer simulation. J Trauma. 1999; 47: 545-550.

Frykberg ER: Medical management of disasters and mass casualty casualties from terrorist bombings; how can we cope? J Trauma. 2002; 53: 201-212.

Peleg K, Aharonson-Daniel L, Stein M, et al.: Gunshot and explosion injuries. Characteristics, outcomes, and implications of care of terror related injuries in Israel. Ann Surg. 2004; 239: 311-318.

Almogy G, Belzberg H, Mintz Y, et al.: Suicide bombing attacks, update and modifications to the protocol. Ann Surg. 2004; 239: 295-303.



How to Cite

Mekel, MD, M., A. Bumenfeld, MD, Z. Feigenberg, MD, D. Ben-Dov, MD, M. Kafka, MD, O. Barzel, MD, M. Michaelson, MD, and M. M. Krausz, MD. “Terrorist Suicide Bombings: Lessons Learned in Metropolitan Haifa from September 2000 to January 2006”. American Journal of Disaster Medicine, vol. 4, no. 4, July 2009, pp. 233-48, doi:10.5055/ajdm.2009.0035.




Most read articles by the same author(s)