When a vehicle becomes a weapon: Intentional vehicular assaults in Israel

Abstract

Background
We have recently witnessed an epidemic of intentional vehicular assaults (IVA) aimed at pedestrians. We hypothesized that IVA are associated with a specific injury pattern and severity.

Methods
Retrospective analysis of prospectively acquired data of patients injured following IVA from October 2008 to May 2016 who were admitted to the Hadassah Level I trauma center in Jerusalem, Israel. Comparison of injury parameters and outcome caused by vehicular attacks to non-intentional pedestrian trauma (PT). Measured outcomes included ISS, AIS, injury pattern, ICU and blood requirements, participating teams, length of stay, and mortality.

Results
There were 26 patients in the IVA group. Mean age in the IVA group was significantly younger and there were more males compared to the PT group (24.7 ± 13.3 years vs. 48.3 ± 21.3, and 81% vs. 52%, respectively, p < 0.01). Lower extremity (77% of patients), followed by head (58%) and facial (54%) injuries were most commonly injured in the IVA group, and this was significantly different from the pattern of injury in the PT group (54, 35, and 28%, respectively, p < 0.05). Mean ISS and median head AIS were significantly higher in the IVA group compared with the PT group (23.2 ± 12.8 vs. 15.4 ± 13.8, p = 0.012, and 4.5 vs. 3, p = 0.003, respectively). ICU admission and blood requirement were significantly higher in the IVA group (69% vs. 38%, and 50% vs. 19%, p < 0.01). Mortality was significantly higher in the IVA group (4 patients, 15%, vs. 3 patients, 4%, respectively, p = 0.036) and was caused by severe head trauma in all cases.

Discussion
The severity of injury and mortality rate following IVA are higher compared with pedestrian injury. The pattern of injury following IVA is significantly different from non-intentional pedestrian trauma.

Conclusions
IVA results in higher mortality than conventional pedestrian trauma secondary to more severe head injury. More hospital resources are required following IVA than following conventional road traffic accidents.

Full text

O R I G I N A L R E S E A R C H Open Access
When a vehicle becomes a weapon:
intentional vehicular assaults in Israel
Gidon Almogy
*
, Asaf Kedar and Miklosh Bala
Abstract
Background: We have recently witnessed an epidemic of intentional vehicular assaults (IVA) aimed at pedestrians.
We hypothesized that IVA are associated with a specific injury pattern and severity.
Methods: Retrospective analysis of prospectively acquired data of patients injured following IVA from October 2008 to
May 2016 who were admitted to the Hadassah Level I trauma center in Jerusalem, Israel. Comparison of injury
parameters and outcome caused by vehicular attacks to non-intentional pedestrian trauma (PT). Measured outcomes
included ISS, AIS, injury pattern, ICU and blood requirements, participating teams, length of stay, and mortality.
Results: There were 26 patients in the IVA group. Mean age in the IVA group was significantly younger and there were
more males compared to the PT group (24.7 ± 13.3 years vs. 48.3 ± 21.3, and 81% vs. 52%, respectively, p< 0.01). Lower
extremity (77% of patients), followed by head (58%) and facial (54%) injuries were most commonly injured in the IVA
group, and this was significantly different from the pattern of injury in the PT group (54, 35, and 28%, respectively, p<0.
05). Mean ISS and median head AIS were significantly higher in the IVA group compared with the PT group (23.2 ± 12.8
vs. 15.4 ± 13.8, p= 0.012, and 4.5 vs. 3, p= 0.003, respectively). ICU admission and blood requirement were significantly
higher in the IVA group (69% vs. 38%, and 50% vs. 19%, p< 0.01). Mortality was significantly higher in the IVA group
(4 patients, 15%, vs. 3 patients, 4%, respectively, p= 0.036) and was caused by severe head trauma in all cases.
Discussion: The severity of injury and mortality rate following IVA are higher compared with pedestrian injury. The
pattern of injury following IVA is significantly different from non-intentional pedestrian trauma.
Conclusions: IVA results in higher mortality than conventional pedestrian trauma secondary to more severe head injury.
More hospital resources are required following IVA than following conventional road traffic accidents.
Keywords: Intentional vehicular trauma, Pedestrian trauma, Terrorism, Multiple casualty incidents, Head trauma
Background
Since the first recorded pedestrian fatality in 1896 in
Europe and in 1899 in the Americas, there were count-
less accidents causing injuries and fatalities from motor
vehicles. In the era of modern motor vehicles, we have
acquired knowledge of the mechanism of injury and
pathophysiology of injury, developed treatments proto-
cols and prevention. These accidents were almost uni-
versally unintentional. Injury caused by a motor vehicle
driven intentionally into a pedestrian crowd with an
intention to cause harm has recently become an uncom-
mon and novel method of terrorism.
This method of attack was first seen in Israel in 1987 dur-
ing the first “Intifada”when a car was intentionally driven to
into a group of soldiers inflicting severe injury. Over the past
decades, there have been random attacks. Since September
2015, we have witnessed a surge of vehicular assaults (Fig. 1).
We suggest the term “intentional vehicular assault”(IVA) to
describe this specific type of violence. IVA is a novel method
used by the lone attacker. Radicals who embark on individ-
ual terrorist missions with little or no logistical support
characterize this ‘lone wolf’phenomenon [1].
Terror acts in the Middle East have evolved from stab-
bings and firearm attacks to suicide bombings. Multi-
dimensional injury caused by terrorist bombings has been
described in the literature [2–4]. Several manuscripts de-
scribe the experience acquired in Israel and analyze the
physical factors that are responsible for injury following
* Correspondence: almogyg@yahoo.com
Department of Surgery and Trauma Unit, Hadassah-Hebrew University
Medical Center, Jerusalem, Israel
© The Author(s). 2016 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Almogy et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine
(2016) 24:149
DOI 10.1186/s13049-016-0338-9

an explosion, the resulting injuries and the appropriate
medical care [5–7].
From February 2008 to May 2016 twenty-nine IVA
with casualties took place in Israel. Civilians were tar-
geted in 15 attacks (52%), and security personnel includ-
ing police officers, border police and soldiers in 14
attacks (48%). Vehicles used to carry out these attacks
included private vehicles (n=18, 62%), heavy mechanical
vehicles (n=5, 17%), commercial vehicles (n=4, 14%),
and trucks (n=2, 7%). Some of the popular sites included
main city streets (n=12, 41%), road blocks (n=7, 24%),
and tram and bus stations (n=6, 21%) (Fig. 2).
Our primary goal was to describe and characterize this
evolving type of violence and the pattern of injury that it
causes. Our secondary goal was to compare injury sever-
ity and outcome following IVA with civilian, non-terror
related pedestrian trauma.
Methods
Data regarding vehicular attacks in Israel was collected
from official governmental sites, published information
and media reports.
Data regarding admitted patients was retrieved from the
Hadassah Hospital Trauma Registry. We retrospectively an-
alyzed prospectively collected data of all victims of vehicular
attacks who were admitted to the Ein Kerem Campus,
Hadassah Hospital level I Trauma Center, in Jerusalem,
Israel, from October 2008 to May 2016. The registry data in-
clude all casualties admitted to the emergency department
(ED) and hospitalized, succumbed in the ED, or transferred
to another hospital following injury. The registry does not
include casualties who died at the scene or on way to the
hospital, patients who were not admitted, or patients who
were admitted only 72 h or later following the event.
Only patients hospitalised following IVA were included
into the study group. The information consisted of the
number hospital admissions, ISS, region injured, surgical
interventions, ICU admission, ICU and hospital length of
stay, and mortality. All injuries were divided into common
anatomic regions (head, face, chest, abdomen, pelvis, upper
Fig. 1 The number of intentional vehicular assaults over recent years, including those with and without casualties. September 13, 2015 marks the
beginning of the ‘Lone Wolf Intifada’
A
B
Fig. 2 Typical pictures from the scenes of two IVA’s in Jerusalem, on
a tram station aand bus stop b. Note signs of a high-energy attack
such as a knocked down electrical pole (a), run over fire hydrant,
and damage to bus stop (b)
Almogy et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2016) 24:149 Page 2 of 5

and lower extremities, spine and burns). Abbreviated injury
score (AIS) was calculated according to injured organs.
The data of the IVA group was compared to 81 patients
between the ages of 18 and 60 who were injured as pedes-
trians in a civilian, non-trauma related setting during 2014
(ICD-10, Pedestrian injured in collision with car, pick-up
truck or van; V03). These 81 patients were defined as the
pedestrian trauma (PT) group. The study was approved by
Hadassah IRB and consent waiver was received.
There are 3 hospitals in Jerusalem serving a popula-
tion of over 800,000 inhabitants. The Ein Kerem
Campus of the Hadassah Hospital is a level I Trauma
Center, Shaarei-Zedek is level II and the Mount Scopus
Campus (Hadassah Hospital) is level III. EMS crews are
instructed to evenly distribute severely injured trauma
patients among the level I and II hospitals. Civilian and
military casualties with moderate and severe head injuries
are preferentially directed to the Ein Kerem Campus.
Statistical analysis
Data are presented as mean and standard deviation (SD) or
number of patients and percentage. The chi-squared test
was used to compare proportions and the Student’st-test
was used to compare continuous non-parametric variables.
Apvalue of 0.05 or less was considered statistically signifi-
cant. Statistical analysis was performed using SPSS version
11.5 (Statistical Package for Social Science, Chicago, Ill).
Results
OurlevelItraumacenterreceived26victimsof13
IVA. The median number of patients admitted to our
trauma center following an attack was one, with a
range of 1 to 5 victims per attack. Their data are shown
in Tables 1 and 2.
IVA vs. PT
Casualties in the IVA group were predominantly male
and significantly younger than patients in the PT group
(Table 1). Seven patients in the IVA group arrived at the
ED intubated (27%), significantly more than in PT group
(n= 6, 7%, p= 0.008). The number of patients who re-
quired surgery was not different between the groups.
However, the mean number of surgical procedures per
patient was significantly higher in the IVA group (1.65 ±
0.7 vs. 1.2 ± 0.5, p= 0.007). Significantly more patients in
the IVA received blood (Table 1), but the number of
blood products per patient was not different.
Head, face, spinal and lower extremity injuries were
significantly more common in the IVA group (Table 2).
Median head AIS was significantly higher in the IVA
group (4.5 vs. 3, p= 0.003, respectively). Following IVA
the teams participating included orthopedics (n= 12),
neuro-surgical (n= 5), spine surgery (n= 1) and plastics
surgery (n= 1). Following PT the teams participating
included orthopedics (n= 29), neuro-surgical (n= 6),
general surgery (n= 6), plastics surgery (n= 2) and ear
nose and throat (n= 2). Combined head, lower extremity
and pelvic fractures were noted only in 2 patients in IVA
group (8%) and 4 patients (5%) in the PT group (p= NS).
Mortality
Mortality was significantly higher in the IVA group com-
pared with the PT group (4 of 26 patients [15%], vs. 3 of
81 patients [4%], p= 0.036). In the IVA group all four
deaths were caused by severe head trauma on days 1 (n=
1), 2 (n= 1), and 4 (n= 2) of admission. The causes of
Table 1 Demographic and admission characteristics in both
types of trauma
Vehicular assaults
(n= 26)
Pedestrian trauma
(n= 81)
Pvalue
Age, mean
a
24.7 ± 13.3 48.3 ± 21.3 <0.001
Sex (males) 21 (81) 42 (52) 0.009
ICU admission 18 (69) 31 (38) 0.006
ICU LOS, mean (days)
a
4.3 ± 6.8 7.8 ± 9 NS
LOS, mean (days)
a
11.9 ± 13.5 11.5 ± 12.7 NS
Required surgery 17 (65.4) 38 (46.9) 0.1
Number of surgical
procedures per patient,
mean
a
1.7 ± 0.7 1.2 ± 0.5 0.007
Received blood in first
24 h
13 (50) 15 (19) 0.0015
The Student’st-test and chi-squared test were used for statistical analysis
as appropriate
Abbreviations:LOS length of stay, ICU intensive care unit
a
Data shown as number (and percentage) and mean ± standard deviation
Table 2 Regions of body which were injured in both types of
trauma
Vehicular assaults
(n= 26)
Pedestrian trauma
(n= 81)
pvalue
ISS, mean
a
23.2 ± 12.8 15.4 ± 13.8 0.012
Head 15 (58) 28 (35) 0.036
Face 14 (54) 23 (28) 0.0176
Chest 3 (12) 25 (31) 0.051
Abdomen 3 (11) 15 (19) NS
Lower extremities 20 (77) 44 (54) 0.04
Upper extremities 8 (31) 29 (36) NS
Spine 7 (27) 9 (11) 0.049
Skin 7 (27) 11 (14) NS
Pelvis 3 (12) 26 (32) 0.04
Vascular 3 (12) 0 (0) 0.0019
Ocular 2 (8) 4 (5) NS
The Student’st-test and chi-squared test were used for statistical analysis
as appropriate
Abbreviations:ISS injury severity score
a
Data shown as number (and percentage), and mean ± standard deviation
Almogy et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2016) 24:149 Page 3 of 5

death for the three patients in the PT were severe head
trauma (day 1), and multi-organ failure (days 28 and 32).
Discussion
IVA have recently emerged as the preferred method of
attack by unarmed and untrained, mostly religiously
motivated individuals, also termed ‘lone wolves’[1]. To
date, these attacks have occurred mostly in the Middle
East and Europe. Since very little training and prepar-
ation is necessary to carry out these attacks, we can
expect more similar attacks on a worldwide basis. An
internet search showed that in Israel the majority of
assaults involved civilian cars although some of them
used heavy construction equipment, making the attacks
more lethal. The number of casualties per attack varied
widely and ranged from one to 70, with a median of 3
causalities per attack. Seven attacks (24%) resulted in
deaths, with a range of 1 to 3 deaths per attack. Two
attacks involved drivers ramming their vehicles into pe-
destrians on the main street, abandoning the vehicle,
and continuing their assault by stabbing passers-by. The
city of Jerusalem was the most common target for IVA.
Fourteen attacks (48%) occurred within the boundaries
of the city and seven additional attacks (24%) took place
in its immediate vicinity (within a range 20 km).
The cardinal finding of this study is that the pattern
and severity of injury following IVA is significantly
different from non-intentional pedestrian injury. Our
data show that ISS is significantly higher following IVA.
This higher ISS is due to more severe head injury that is
characterized by higher head AIS. The higher fre-
quency of lower extremity injuries during IVA com-
pared to PT further supports our assumption that IVA
causes a different pattern of injury.
Age and severity of head injury exert the strongest
impact on prognosis and mortality following motor
vehicle accidents [8]. Strikingly, the IVA group had
significantly higher mortality compared to civilian pe-
destrians (15% vs. 4%, p= 0.036), and this difference
was secondary to head trauma. All 4 deaths in the IVA
group were caused by severe head injuries, compared
to only one death in the PT group. This correlates well
with the fact, that it is exactly these two factors, mor-
tality and head trauma, in which IVA and the control
group differ the most in our analysis.
In addition to a significantly higher rate of severe head
injury, the IVA group also required significantly more pre-
hospital interventions. The intubation rate was almost
four-fold higher in the IVA group (27% vs. 7%). The sever-
ity of injuries, specifically head injury, and despite the
scoop and run regime of emergency teams, and short
transport times, could be an explanation for the higher
intubation rate. Similar findings are apparent concerning
in-hospital surgical procedures. The IVA group presented
severe injuries making surgery necessary in nearly two-
thirds of cases. This is in contrast to pedestrians who
underwent operations in less than half of cases.
Our data show that victims of IVA were younger. This
represents the younger age of security personnel, com-
pared to the average age of civilian pedestrians. A similar
age pattern was observed in previous studies on suicide
bombing attacks published from our institution [9, 10].
As a consequence of a non-intentional related car
accident, the pedestrian is hit by a car which is deceler-
ating, and the victim is often shoved away with injury to
the extremities and pelvis, but with less severe head
trauma. At this point of time, we can only try to under-
stand the mechanism injury following an IVA. By study-
ing available sources such as video clips and witness
reports, we anticipate that deliberate acceleration of the
vehicle into an upright pedestrian may lead to high energy
trauma to the lower extremities and to severe head trauma
when and the victim is hurled towards the vehicle. In fact,
our results showed this particular type of injury pattern in
the IVA group (lower extremities and head trauma), as
opposed to more pelvic injuries in the PT group. More
studies are necessary to clarify this phenomenon.
This general pedestrian injury pattern is supported by
the classic theory of pedestrian versus motor vehicle
kinematics [11]. However, more recent investigations
demonstrated significant inter-individual variations in
common pedestrian injury combinations that are influ-
enced by several factors (e.g., vehicle type, body region
of first impact, main impact direction etc.) [12–15]. Our
data confirms this conclusion. We were unable to iden-
tify the classic pedestrians “fatal triad”of injuries as
described by Farley and Waddell for severely injured
victims [16, 17]. Only a few patients had all three injur-
ies, and there were no differences between the groups.
Previous reports have shown that terrorist attacks
strain and challenge hospital resources when compared
to civilian trauma. Our data show that the number of
surgical procedures per patient, ICU and blood transfu-
sion requirements, were significantly higher following
IVA compared with PT. The severity of head injury
among patients with head injuries was also significantly
higher following IVA. Thus, more resources are needed
to manage victims of intentional trauma compared to
non-intentional trauma.
The median number of casualties who were admitted
to the ED following an IVA was relatively small (range
of 1–5 victims/attack) when compared with the number
of casualties following other types of terror acts such as
suicide bombing attacks. However, four IVA resulted in
multiple casualties and can be defined as multiple cas-
ualty incidents (MCI, defined as ≥10 casualties arriving
at hospital). In fact, there were 70 casualties when a bull-
dozer rammed into a crowd on a Jerusalem main street.
Almogy et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2016) 24:149 Page 4 of 5

Likewise, there were more than 200 casualties following
the Nice (France) attack (July 14, 2016) which involved a
truck. Admitting hospitals are required to prepare for an
MCI following IVA.
Conclusions
In conclusion, victims of IVA are characterized by severe
head injuries and a higher subsequent mortality when
compared to pedestrians involved in non-intentional
road traffic collisions. Increased hospital resources are
required to appropriately manage IVA. Attention should
be given to constructing anti-vehicle barriers and other
passive protective means to shield pedestrians in popular
sites which may serve as potential terrorist targets.
Abbreviations
AIS: Abbreviated injury score; ED: Emergency department; ICU: Intensive care
unit; ISS: Injury severity score; IVA: Intentional vehicular assault; LOS: Length
of stay; MCI: Multiple casualty incidents; PT: Pedestrian trauma
Acknowledgments
The authors would like to thank Ms. Andrea Michelle Lowenstein for
proofreading the manuscript.
Funding
The authors declare no funding of this study.
Availability of data and materials
The datasets during and/or analyzed during the current study available from
the corresponding author on reasonable request.
Authors’contributions
Acquisition of data: GA, AK, MB; Analysis of data: GA, AK, MB; Drafting of
manuscript: GA, AK, MB; Critical revision: GA, MB. All authors read and
approved the final manuscript.
Competing interests
The authors declare no competing interests.
Consent for publication
Not applicable.
Ethics approval and consent to participate
This study was approved by the institutional review board (IRB, ‘Helsinki
Committee’) at Hadassah Hospital.
Received: 20 September 2016 Accepted: 28 November 2016
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