Introduction: Mass-casualty incidents (MCIs) can occur outside of major metropolitan areas. In such circumstances, the nearest hospital seldom is a Level-1 Trauma Center. Moreover, emergency medical services (EMS) capabilities in such areas tend to be limited, which may compromise prehospital care and evacuation speed. The objective of this study was to extract lessons learned from the medical response to a terrorist event that occurred in the marketplace of a small Israeli town on 26 October 2005. The lessons pertain to the management of primary and secondary evacuation and die operational practices by die only hospital in the town, which is designated as a Level-2 Trauma Center. Methods: Data were collected during the event by Home Front Command Medical Department personnel. After the event, formal and informal debriefings were conducted with EMS personnel, the hospitals involved, and the Ministry of Health. The medical response components, interactions (mainly primary triage and secondary distribution), and the principal outcomes were analyzed. The event is described according to Disastrous Incidents Systematic Analysis Through Components, Interactions, Results (DISAST-CIR) mediodology. Results: The suicide bomber and four victims died at the scene, and two severely injured patients later died in the hospital. A total of 58 wounded persons were evacuated, including eight severely injured, two moderately injured, and 48 mildly injured. Forty-nine of the wounded arrived to the nearby Hillel Yafe Hospital, including all eight of the severely injured victims, the two moderately injured, and 39 of the mildly injured. Most of the mildly injured victims were evacuated in private cars by bystanders. Five other area hospitals were alerted, three of which primarily received the mildly injured victims. Two distant, Level-1 Trauma Centers also were alerted; each received one severely injured patient from Hillel Yafe Hospital during the secondary distribution process. Emergency medical services personnel were able to treat and evacuate all severely and moderately injured patients within 17 minutes of the explosion. A total of 12 of the 21 ambulances arriving on-scene within the first 20 minutes were staffed by EMS volunteers or off-duty workers. Conclusion: When a MCI occurs in a small town that is in the vicinity of a Level-2 Trauma Center, and located a >40 minute drive from Level-1 Trauma Centers, die Level-2 Trauma Center is a critical component in medical management of the event. All severely and moderately injured patients initially should be evacuated to die Level-2 Trauma Center, and given advanced, hospital-based resuscitation. The patients needing care beyond the capabilities of this facility should be distributed secondarily to Level-1 Trauma Centers. To alleviate die burden placed on die local hospital, some of die mildly injured victims can be evacuated primarily to more distant hospitals. The ability to control die flow of mildly injured patients is limited by die large percentage of diem arriving by private cars. The availability of EMS in small towns can be augmented significandy by enrolling off-duty EMS workers and volunteers to die rescue effort. Level-2 hospitals in small towns should be prepared and drilled to operate in a "selective evacuation" mode during MCIs.
