A 6-kg explosive charge detonated under a seat in the center of a crowded city bus in Jerusalem, killing three passengers immediately. Of the 55 survivors, all of whom were transferred to two major medical centers, 29 were hospitalized. Among those admitted, a high rate of primary blast injuries was found, including perforated ear drums (76%), blast lung (38%), and abdominal blast injuries (14%). Two of the latter patients suffered bowel perforations, which were diagnosed with considerable delay. Eight patients (31%) had sustained life-threatening trauma, consisting of a combination of primary, secondary, and tertiary blast injuries. The overall mortality rate was 10.3%. The large number of primary blast injuries, including the unexpected finding of bowel perforations, is explained by the high amplitude of the air pressure wave (3.8-5.2 atm) and its relatively long duration (2-3 msec) resulting from the detonation of the high-energy explosive charge in the small, enclosed space of the bus. Besides the usual wounds sustained by victims of an explosion that occurs in a confined space, the possibility of primary blast injury to the abdomen and to the lungs should be taken into account by the treating surgeon.

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During the academic years I 9 75 and I 9 76 an interdisciplinary course in mass casualty management was given to sixth year medical students at the Hebrew University-Hadassah Medical School in Jerusalem. The course included introductory lectures in definition of types of disasters, objectives in disaster intervention, description of local and national rescue organizations. Special importance was paid to mage of casualties and to a centralized system of evacuation from the disaster site. Further, hospital planning and deployment, stressing the role of the Emergency Room physician. The specific approach to multiple injuries including neurosurgical, orthopedic, abdominal, chest and soft tissue wounds was discussed in a panel meeting. Stress intervention and a comprehensive lecture on public health problems concluded this part of the course. The last half-day was devoted to a practical exercise, simulating a town severely damaged by an earthquake. Although the course was an elective one, it was extremely well attended by the students, and its implementation was enthusiastically performed by both teachers and students.