Editorial Commentary

The unsettling and sad reality of our world today is that, anywhere and at any time, terrorist attacks, large and small, can occur without warning. For decades, hospitals, law enforcement, and emergency response teams have conducted "disaster drills" and created disaster preparedness policies and procedures in the event of natural and manmade disasters. The recent events in Nice, France, where more than 80 people were struck down and killed (Bratu & Saliba, 2016), Baton Rouge, LA, and Dallas, TX, where police officers were murdered (Bradner, 2016), and Orlando, FL, where 49 people died and 53 were wounded (Alvarez, Perez-Pena, & Hauser, 2016), and continued reports of violence all too often force us again to think globally and be concerned about our fellow citizens around the world. We all need to reexamine our own preparedness and be ready for anything. With sincere appreciation to our colleagues in Israel, we thank the contributors of the article that follows for sharing their insights.

Since September 2015, Israeli citizens have been facing a rise in terror attacks. Unlike the bombings that preceded this period, the recent attacks have been mostly stabbings. Tourists are not immune from these assaults. On March 8, 2016, a terrorist killed an American tourist and wounded at least 10 other victims when he went on a stabbing spree that began in southern Tel Aviv's Jaffa Port. Among the wounded, four were in serious condition, including two Russian tourists who constitute our case study. There were also another four victims who were in moderate condition, and two others suffered lesser wounds.

When an Israeli is wounded, he or she will be discharged home or to a rehabilitation center as needed. The difficulty in this case was that two tourists were severely injured and treated in two different hospitals. Because of the severity of their injuries, a flight home was contraindicated. Therefore, the couple was unable to return to their home hospitals/country and required acute care hospital in Tel Aviv, necessitating accommodations and medical and social coordination.

We have selected this case to demonstrate the range of services available and delivered through the Terror Victims Unit. This process incorporated medical and social case management (Case Management Society of America, 2016; Department of Health and Human Services, 2009). Client-centered medical and nonmedical collaborative processes, with a range of services, including coordination and follow-up of medical treatments, referrals to appropriate providers, and resources were utilized. Case management included various components and specificities:

* Identification and tagging as terror victims, allowing direct national management.

* Medical and social coordination at the national level, making access to hospitals and health maintenance organizations (HMOs) available.

* Centralized standardization.

* Centralized financial authorization. Receipt of National Insurance Institute of Israel (NII) funds obliged all the providers to notify and keep the NII informed accordingly.

* Diversity of injuries, acuity levels, and medical background (physical or mental).

* Emergency situations.

* Immediate- and long-term approaches.

* Hospital and ambulatory care. (Shamai & Ron, 2009)

The NII is responsible for providing medical case management and social coordination for terror victims. The NII Terror Victims Unit is composed of a National Insurance Physician (NIP) and specialized social workers coordinating and communicating, on a daily basis, with all hospitals and local HMOs; these are called "Kupot Holim." There are four state-mandated health service organizations, charged with administering health care services and funding for its members and cover all citizens, as well as victims of terror attacks, and in multiple languages. The treatment is delivered, as needed, facilitated through the NII officer's authorization.

We conducted a thorough analysis of medical and social reports coming from hospitals and the NII, along with interviews of an NII physician and social workers related to our case. This is a strict description of facts and circumstances and is followed by a discussion relative to case management and its importance and specificity for terror victims.

Case Presentation

Two Russian tourists, both 31 years old, visited Israel from the Krasnodar region of Russia. They were both severely injured and transferred to two different hospitals for surgery and other medical treatments. The couple had one 2-year-old daughter, who had remained in Russia with her grandparents in their home. One close Israeli friend, a lawyer, had helped them through the process, mostly by providing interpreting and translation services.

The Medical Management

The husband suffered a direct stab attack and sustained an injury to the left eye that was so severe that he suffered complete loss of vision in that eye. The attacker has transected the optic nerve, as well as inflicting other lacerations to the victim's neck. The male victim also sustained skull fractures, which were treated by two neurosurgical interventions. His wife was attacked in the back and stomach and suffered injuries to the small intestine and abdominal wall; her injuries included evisceration. She was also cut on the finger, scalp, and chest. Nineteen days after the attack, the medical dossier (record) was transferred to the NIP in charge.

After the wife's release from the hospital, the NIP authorized the delivery of 3 months of treatment directly to the medicalized hotel. A medicalized hotel is a structure with medical and paramedical follow-up services, especially designed for posthospitalization and rehabilitation. The couple insisted on returning to Russia at the end of March 2016. Together with the hospital team, the NIP decided to check their medical status and stability to fly with a specialist. To accomplish this, a computed tomographic scan was done on the husband, as an immediate (STAT) test and results obtained the same night showed a gaseous embolism. It was decided that his flight must be postponed. As to the wife's flight, it was allowed, but only in business class. On April 4, 2016, to incorporate the psychological component, psychiatric and psychological support was initiated for the husband for posttraumatic stress disorder with a Russian-speaking psychiatrist.

The Social Management

The morning after the attacks, with the help of the Russian-speaking close friend of the couple who provided all necessary information, the NIP and social workers were in direct contact with the couple and their family. At the same time, the case was presented to the Terror Victims Unit in order for the couple to be officially recognized as victims of terror by the State of Israel. On March 31, 2016 (less than one 1 month after the incident), the couple was officially designated as victims of terror in Israel. After her 12 days of hospitalization, the wife benefited from a medicalized hotel near the husband's hospital. In addition, Israel paid for the wife's mother's flight to Israel, in order for her to be present to support her daughter. On April 4, 2016, because it was still medically unsafe to allow them to return to Russia and to fortify the family unit, the couple benefited from the medicalized hotel, providing one room that could accommodate both the husband and the wife, as well as another room for the wife's mother. On the same day, a bank account was opened by the couple in Israel so that they could conveniently receive funds to provide them with financial support, medical treatment compensation, and rehabilitation for each person affected by the terror attack. The victims receive funds while in Israel and will continue to receive a monthly stipend. Once the team determined that the wife and her mother could return to Russia, the husband's mother would come and stay in Israel until it was safe for him to travel.

Before his return to Russia, numerous evaluations were conducted, utilizing specialists from many disciplines, to determine the level of disability. The couple will be followed, even after their return home to Russia, as they receive a monthly allowance due to their "victim of terror" status.

Discussion

The law that guarantees various social, financial, and medical services and assistance to terror victims is the Victims of Hostile Action Law ("VHAPL"), which was enacted by the Israeli Parliament in 1970 (Sommer, 2003). The NII is responsible for providing these services, whereas costs are financed by the Israeli treasury. To be eligible for compensation, the victim should have legally entered Israel and been wounded in Israel's territory, which includes tourists. The victims are reimbursed for all surgical and medical treatments (related to this event and in public hospitals and HMOs), which offer a broader scope of services than those found in the United States. Services include hospitalization, outpatient care, rehabilitation, medications, medical devices, mental health interventions, and so forth. In addition to the medical treatment, a terror victim could benefit from psychological and psychiatric support and can submit an application for a disability lump sum payment or monthly compensation (Gagin et al., 2007).

Conclusion

The State of Israel supports victims of terror. This support goes beyond immediate treatment and includes medical, psychological, and social case management. As terror is increasing in the United States and Europe, the unique Israeli experience and well-established system for victims' support can serve as an admirable illustration of leadership and compassion to inspire other countries to follow its example. Using patient-centered case management, creative interventions, along with centralized financing, are effective and manageable and serve Israel and its visitors.

Acknowledgments

The authors thank the entire team in Jerusalem at National Insurance Institute of Israel and all the contributing hospitals.

References