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“…And then I understood that these people are still very close to a killing reality, blood, for them, is a familiar liquid…in the East the holy and symbolic meaning of killing is still known, as well as the mystic and sensual meaning…. Everybody smiled…as if the killing was a good and a burning act. We are Westerners, and for us, killing is a legal and moral question…. We also kill, but…we have guilty feelings. Our history includes mass-murders, but when we are talking about killing our eyes are lowered and our voice is reprimanding.”

Sandor Marai, the Hungarian author, describes his encounter with Arabs in his book Embers (1942).

We are currently acknowledging what Sandor Marai noticed more than 50 years ago: the sanctity of human life and existence is perceived in a profoundly different manner by the free, democratic people of the world and a large enough minority of Arab and Muslim factions. Following this assumption, one may argue that terror acts that the people of the West recognize as immoral and intolerable are not only recognized as heroic by certain groups and individuals, but viewed as symbolic, mystic, and sensual.

Terrorism, which not long ago was perceived as a regional problem in developing and third world countries, has evolved into a threat to the delicate network of everyday life in developed countries. The September 11, 2001, coordinated attacks on symbols of American dominance, the July 7, 2005, attacks on the London public transport system, numerous attacks on Israeli civilians, and the ongoing vicious sectarian violence in Iraq exemplify the magnitude of this threat. Attacks on places of leisure and relaxation such as cafés and restaurants have shaken our sense of security. This is the goal of terrorists, and it has been attained to some extent in many regions.

Muslim terrorist groups identify Israel and the United States as the main threat to Muslim purity and culture and the future expansion of Islamic rule. Foreign presence in the holy cities of Mecca and Medina (Saudi Arabia), and Israeli rule of “divine” Muslim land in Israel, serve to justify the killing of innocents.

Compared with other types of terrorist attacks, suicide bombing attacks have emerged as a lethal and inexpensive means of terrorizing a population to achieve political goals. First used in Lebanon by Hezbollah, suicide bombing attacks are presently being used by radical Islamists to fight a jihad against their enemies, with total disregard for civilian casualties. The present al-Aqsa Intifada in Israel has exposed the medical world to the devastating capability of a suicide attacker to mingle within a crowd and detonate a large explosive device coupled with heavy shrapnel.

Detonation of an explosive device causes injury in 4 mechanisms including blast wave, penetrating shrapnel injury, impacting objects, and burns. The result of this unprecedented number of suicide attacks in Israel has been a large number of casualties suffering from a combination of blast injury, penetrating wounds, and burns. Survivors will present with severe blast lung injury coupled with penetrating head, torso, and limb wounds. The presence of non-blast-related injuries caused by impacting objects, and falls such as fractures, should not be overlooked.

Medical systems are well prepared, staffed, and equipped to deal with a small number of civilian trauma victims. Admitting teams will receive information regarding number of victims, mechanism of injury, and the victims’ condition. Once the victims arrive in the emergency department, fully staffed teams will examine them and determine a plan for immediate and late treatment and management.

Quite the opposite is true of mass casualty incidents such as following a tsunami or earthquake where medical systems are overwhelmed. Resources such as personnel, medications, and hospital beds are inadequate and appropriate care cannot be delivered to all victims.

The approach to the care of victims of terrorist bombings differs vastly from the everyday situation on one hand and the mass casualty scenario on the other. The combination of the influx of a large number of severely injured victims with complex wounds caused by a variety of mechanisms is the hallmark of terrorist bombing attacks. Chaos, an integral part of terrorist attacks, confounds the efforts made by the admitting teams to control the situation.

To manage these demanding and tense incidents it is essential to carefully form, drill, and eventually execute a comprehensive policy. Drills based on real-life scenarios form the basis of preparation for these attacks. In Israel, guidelines for cooperation and responsibility between the different emergency services including paramedical teams and police units are clear and preestablished. A centralized command system at the scene and a preformed triage plan are essential to provide rapid and safe evacuation of victims.

Triage is of paramount importance if we are to provide the victims with the best possible care. Accurate in-hospital triage is crucial to avoid over- and undertriage, which can be catastrophic in these situations. The diagnostic significance of certain external signs of trauma assists the triaging officer to direct victims to the appropriate level of care and need to be integrated into triage protocols. Limited hospital resources such as experienced and qualified staff, operating rooms, intensive care unit (ICU) beds, and imaging facilities are shifted toward the care of terror victims by postponing elective procedures.

A coherent and simple chain of command led by an experienced trauma surgeon is established. An organized and centralized in-hospital decision-making body made up of department chairpersons and hospital administration controls chaos and optimizes resource utilization. Recruitment of experienced personnel from all fields of trauma care is crucial.

Because of the pivotal role surgeons play in trauma care and in disaster planning, it is imperative for surgeons to understand the features associated with terrorist attacks in general and the unique injuries sustained by victims of suicide bombing attacks in particular. These upcoming 2 issues of Current Problems in Surgery will present and discuss the differences between managing terrorist trauma, focusing on suicide bombing attacks and other forms of trauma.

The following 2 issues of Current Problems in Surgery are based on experience acquired at the level 1 trauma center at Hadassah University Hospital in Jerusalem, which admitted the largest number of victims of suicide bombing attacks in Israel, and additional experience from Israel, Madrid, London, and New York and other terrorist bombing attacks. We will present the history of terrorism, its targets and tactics; prehospital and in-hospital preparation and protocols; the scope of injuries; incident management through these demanding events; and finally, several futuristic ideas for improving prevention and care.