Principles of mass casualty management following terrorist disasters.

Interesting times, indeed. We are now living in an era of unprecedented medical advances in patient care and quality of life, but at the same time face some of the most daunting challenges to ever confront the surgical profession. The 3 papers featured in this issue of Annals of Surgery that describe the unique characteristics and management principles of mass casualties from recent terrorist violence in Israel illustrate one of the most prominent and timely of these challenges to our skills, our adaptability to adversity, and to our commitment to the care of the injured. The massive numbers of casualties that exceed the resources of most hospitals, the victimization of innocent civilians, including children, and the especially severe and extensive patterns of injury that characterize current terrorist attacks, go so far beyond the standard surgical training and experience of most of us, that a basic change in mindset is necessary in our approach to medical care of these victims to maximize the salvage of life. Almogy et al document the high ratio of dead:wounded from suicide bombings to range from 5–22, which is an order of magnitude above the 1:2 – 1:5 reported in conventional military combat experiences. Peleg et al report the inpatient mortality following terrorist bombings and shootings to be twoto 3-fold higher than that following motor vehicle crashes and other standard forms of trauma. These studies by our surgical brethren in Israel offer important lessons to surgeons around the world who rarely, if ever, experience true mass casualty disasters involving bodily injury, and yet who are increasingly likely to face such scenarios in the near future in the current political climate. Until recently, the United States, in particular, has been largely spared the horrors of terrorist bombings and shootings that Israelis experience virtually every day and, as a result, we are poorly prepared for the demands of caring for such large numbers of severe injuries. Although Americans have suffered several terrorist attacks and substantial loss of life from these causes over the past 20 years, and the threat of more attacks rises, we tend to have a short memory. The same mistakes continue to