Final thoughts before flying back: was the trip worth it?

I am writing this at the airport as I leave Israel, so this may be my final blog of this war.

 

I hope you will forgive this one sounding a little self-centred, but as I come to the end of this period, I wanted to gather my thoughts on the pros and cons of coming out to Israel. I don’t mean this to sound self-congratulating, but sometimes you wonder if you make a difference, and I thought it would help to reflect on some achievements. 

 

Starting with the clinical side (and a warning that some of the details are a bit graphic). I came out a full week after Oct 7^th and wasn’t there to help with the immediate flood of patients to Barzilai that day. 

 

I was however involved in treating a number of those casualties a week later:

There was the fighter from the security services I wrote about earlier, who was shot on the roof of the Sderot Police station. By the time I arrived his main issue was severe neuropathic pain from the bullet in his thigh and pain from his pancreas injury. Barzilai unfortunately doesn’t have an Acute Pain Service, and here I felt that I could contribute something: I called my former teacher and head of the Hadassah Pain Clinic, Prof Eliad Davidson, and he gave us advice on pain management for this patient. It turns out that Hadassah also had some severe and painful injuries from Oct 7^th, and are rapidly building further experience there.

 

Then there was the patient who drove a “Tractoron” (maybe Quad bike?) on Oct 7^th, and was shot in the jaw, destroying half his mandible and requiring emergency cricothyroidotomy. He was lucky that the bullet didn’t hit any major blood vessels, but when they did the CT they saw that blood flow was nevertheless blocked in those vessels. When he woke they found that he had had a stroke, but the repeat CT showed that the vessels were now open. Apparently they had spasmed due to the bullet shockwave and later re-opened. I mention this because it informed the way I treated a later patient following the ground entry on Oct 29^th.

 

There was a man who went fishing on the coast on Oct 7^th and was shot in the eye and chest, losing his eye, getting mediastinitis (infection near the heart), and requiring a tracheostomy. In addition to general care for him, I had one moment when I do feel I helped a bit more: I was sitting at the nurses station typing notes when I heard the nurses ask each other “Where is Dr …. (one of the ICU attendings)”, I was behind with my notes so kept typing. Then I heard “His tracheostomy has come out”. I leapt up and went to the room. The tracheostomy indeed was half out, with just the inflated balloon at the level of the skin. This was enough to allow the ventilator to tenuously ventilate the patient. I immediately turned the vent up to 100% oxygen to buy time, and tried to push the tracheostomy back in place. This was a little traumatic with some fresh blood around it, but with the balloon deflated I got it in, and then re-inflated the balloon. I confirmed positioning with the CO2 monitor, that the vent was producing good ventilation volumes, and then passed a flexible suction catheter down the tracheostomy, confirming it passed easily and sucking up a bit of fresh blood. At this point the ENT surgeon arrived breathless. He took a look with a fibreoptic scope down and confirmed that the tracheostomy was back in place.

 

The next patient was a lady in her 60s who had been shot in the abdomen, and had required bowel resection and a stoma. After a week she was doing great and the surgeons kept asking to discharge her to their ward. The only thing was that every morning she would desaturate and require respiratory support. Eventually she improved and went to the ward.

 

Finally there was the patient who I consider to be a war casualty although I doubt he will be counted as one.

A schizophrenic who got so scared of the rockets, he locked himself in his bathroom for 5 days, having food and water brought to him by his family. Eventually he developed necrotising fasciitis/Fournier’s gangrene (a.k.a. “flesh eating bug”) where the bacteria spreads rapidly, killing the tissue ahead of it so antibiotics don’t penetrate well. The only treatment is surgery and often repeated surgery. Simultaneously he had a massive pulmonary embolism (life threatening clot in the lungs). When he got to the hospital a difficult decision was made whether to give him TPA (an extremely powerful clot busting drug, that makes you bleed lots) or widespread surgery, and he went for surgery. When he came to us post-op to the ICU, we were in a dilemma. He had open wounds that were oozing blood, but still this huge clot in the lungs. Here I contributed something: At Penn we have a service where the cardiologist enters a vein and snake a wire up to the lungs, grabbing the clot and sucking it out. This way you can avoid some of the clot busting TPA that would make him bleed. When I suggested this, they said they hadn’t heard of this being done at Barzilai but we spoke to the cardiologists. They hadn’t done it themselves but consulted with Ichilov Hospital in Tel Aviv, and eventually the patient was transferred there.

 

That was in my first 2 weeks here. Then came the ground incursion on Saturday Oct 28^th. I arrived at work as usual on the Sunday, sitting with the anaesthetists having coffee when they asked where is Dr G… (the resident on-call overnight). “Oh, he is in the Trauma Bay dealing with the trauma that just arrived”. I headed over to get to know a patient who likely would come to my ICU. There I saw a reservist soldier who had just come in with shrapnel to his arm, his lips/chin and most seriously, to his neck with a bulging haematoma. The trauma leader very reasonably decided to sedate and intubate the patient to protect his airway, in case the bleeding in his neck expanded and closed his trachea. Here I lent a hand, bringing the video laryngoscope when the direct laryngoscopy failed, transporting the patient to the CT scanner, bringing him to the ICU, and knowing his story to hand-over to the ICU staff. Following what happened to the previous patient who had unexpectedly suffered a stroke despite no large vessel injuries, I felt it was important to wake this guy as early as possible, so that we could make sure he was neurologically intact. The initial thought on the ICU was to keep him ventilated for 24 hours as a precaution, but I and one of the attendings pushed to wake him sooner, and so after he had an endoscopy to make sure his oesophagus wasn’t injured, we woke him that afternoon. In the evening he was already eating and drinking and asking to go home, and the following day he was discharged to the ward. 

 

Following the work in the Trauma Bay, I had a couple of small feedback suggestions for how to do things differently, so perhaps that cross pollinations of ideas may be helpful too.

 

Those were the casualties we treated directly on the ICU. However there were also the casualties we ended up NOT treating in the ICU. Because of the war, the ICU attendings tried not to admit patients unless they really needed it. We never knew whether there was going to be another huge attack and we’d need the ICU beds. 

So there was the lady after urology surgery who got re-intubated in the post-op area, and started to become septic. Or the patient with angioedema and a big swollen tongue threatening to obstruct his airway and needed to be observed. In those cases we kept them in the OR Recovery Room, but I would drop by throughout the night and check up on them. 

 

Beyond this clinical side, people seemed to really appreciate having volunteers come out to help, and it seems to go beyond any practical impact of anything we actually did. I admit this felt odd, because visiting for a few weeks with my family safely in America, felt far less brave than what the residents of Ashkelon and the south did every day, living under fire, with their families next to them. But I kept getting thanked profusely for coming out. 

 

Beyond the clinical work, there was also perhaps some help in terms of describing the situation to people further away, acting as an information bridge. This blog tried to do that, as well as an interview I did (not very well) with Channel 12 TV.

 

But, in addition to conveying information, there was also conveying actual things. When I was heading out, I was approached by Cindi, a childhood friend of my mother-in-law. She had been collecting clothes and equipment for soldiers on the front, and asked if I could help carry them. I agreed, provided the airport security were OK with this. The next thing I know, I’m piling 4 huge duffel bags packed full of heavy stuff onto my trolley, and Cindi is swiping her personal credit card to pay for excess baggage.

 

Looking back at all this, it does feel like this trip made a contribution. Not world changing, but worthwhile. 

 

I’m left with a huge sense of gratitude to have been able to come out to Israel and Ashkelon during this time. As doctors there are rare moments where you are struck how people are letting you into their lives in situations when they are most vulnerable, and what a privilege this is. Today I feel like coming out here was one of those times.

 

I’m so grateful to the staff at Barzilai who welcomed me into their team, and all the many people who support this, including Ayelet looking after the kids, our community in Philadelphia looking after her, Barbara and Alan who hosted me in their home, and the Penn doctors for the emotional support and for swapping my clinical days.

How not to act in a rocket attack / My closest rocket attack of this war.

I was driving back from visiting my family in Netanya, toward Barzilai Hospital, when my phone pinged saying there was a Red Alert siren in Ashdod.

I think, “Wait a moment. Aren’t I passing Ashdod now?”

I open the window to see if I can hear a siren. I hear a quiet distant siren

Should I pull over? But the other cars are still driving, so like a sheep, I keep driving.

I see a yellow light slowly rising in the sky above me. 

“That looks like a Hamas rocket” I think. 

But the other cars are still driving, so I keep driving.

The rocket leaves my field of vision.

Then there is a big bang that makes me jump. 

Now the car in front pulls over and the driver gets out and sits down on the ground. 

Finally I follow suit and do the same.

The news reports that a rocket made it past the Iron Dome air defence system and hit the ground near Ashdod. There were no injuries.

My patient, the hero

There’s no way I can do justice to the story I heard tonight, but feel like I need to tell it anyway. In truth, I’m not even sure a Hollywood film director could do it justice. Some of it also gets pretty grisly, so take this as a warning.

 

Tonight during my on-call, I heard one of my patients, who I will call Ari (not his real name) talking to his nurse, telling her how he got to the ICU. Things were quiet on the unit and so I asked if I could listen too. What followed was us standing next to his bed for a full hour, while he told us his story of how he was injured on October 7^th. 

 

He works as a fighter in one of the security services, and was heading home after overnight work. On the way home he stopped at a petrol station, when he started to hear the air raid sirens and rockets coming in. His intuition was to head straight home, but his wife told him on the phone to stay and take cover in the gas station secure space, which in retrospect saved his life. It turns out that there were terrorists outside his village, and they were shooting and killing any car that approached, and had he driven home he would likely not have survived.

 

At this time Ari started hearing shouts of “Alahu Akhbar” along with shots, and realised that in addition to the rockets, there was an infiltration of terrorists into Israel. He was armed only with his personal Glock 9mm handgun, so he drove to the Sderot police station, hoping to pick up a rifle there, and then to go out and defend the communities.

 

At this point I got called away to see another patient, so I missed part of the story, but from what I gathered when I got back, at the police station he didn’t get a chance to get a rifle. Eighteen seconds after he walked in, the terrorists arrived in a pickup truck. There was a family car outside, and they shot the parents, thankfully ignoring the screaming kids in the back. They then broke into the police station, using rockets (or perhaps RPGs) and AK-47s. 

 

Ari ran up to the roof of the police station, along with I think it was 3 male and 2 female police officers. They had assault rifles and he still only his handgun. He drew me a diagram, and it showed two entries onto the roof, with a wall around the edge, and a number of solar panels in the middle. The police officers positioned themselves in the corners, but he knew that with only a handgun, he’d need to be close to the terrorists when they broke onto the roof, and so hid behind a solar panel. 

One of the female officers, Nurit (also not her real name), sounded terrified, and he managed to break into a generator room on the roof, trying to hide her inside, but she refused.

 

They took up their positions, before two terrorists broke out onto the roof. The first one was a giant of a man, carrying an AK-47. My patient jumped out of hiding and emptied a magazine into both of them from a few meters range. He remembers who the terrorist looked down and saw his injuries. Ari stepped away to reload, and the range was so close that the terrorist didn’t even bother aiming his assault rifle. He simple held it horizontally and sprayed his target. Ari immediately felt a bullet hit him in what he thought was his foot, but he looked down and couldn’t see any blood. It turned out eventually to be a shot in the thigh that had hit the nerve, causing referred pain and loss of feeling in his distal foot. Meanwhile the terrorist collapsed dead from the hits of Ari’s bullets.

 

At this point he was the only one injured. As he sat there he called over the police woman, M, asking her to give him her shirt to make an arterial tourniquet. She didn’t know how, and another policemen there said he wasn’t sure, so my patient talked them through it. In retrospect he said that the tourniquet must have not been tight enough, because given that it ended up staying on for 7 hours, he would have lost his leg if it had been.

He then realised that he had been shot in the abdomen as well, and he tried to plug the hole with his finger (I didn’t break it to him that this won’t do much for abdominal gun shot wounds). Soon afterwards he started coughing up blood, and it was only then that he realised how seriously injured he was.

 

Nurit kept talking to him and reassuring him, promising him that he would see his 1½ year old boy again. He told me how she was engaged to be married, so I guess they spoke about that too.

 

Soon after this, and while still talking to her, Nurit was suddenly shot in the head and collapsed, along with a police man next to her. A Hamas sniper had managed to get onto a nearby roof and simply shot them both in the head. Ari told me several times how sudden it was. That she wasn’t “Gosses” (ancient Hebrew for someone who is dying) – she simply collapsed in front of him mid speech. The police officer next to her, also shot in the head, had blood sprayed all over the wall behind him “like in the movies”. A third police officer next to him was also shot in the head but this time it seems to have glanced off the back of his skull, taking a lump of bone with it. My patient described how he was surprised at how little blood there was, but that he could see the policeman’s brain pulsating in his skull. Meanwhile the police officer kept talking. Ari couldn’t bring himself to tell him about his horrific injury, believing it would make him panic. Miraculously that police officer survived, and ended up being taken to Barzilai Hospital and then on to the trauma centre at Tel Hashomer for neurosurgery.

 

My own patient, Ari, was still lying on the floor, which is why he survived. Most of the others on the roof were killed by that sniper. 

 

He also describes how another police woman played dead in the far corner, covered in water from a burst pipe. At one point one of the hand grenades thrown by the terrorists landed next to her (I forgot to mention that they were using those too), and she quickly picked it up and threw it back at them. She suffered only a mild shrapnel injury to her hand, and actually visited Ari at the Barzilai ICU in the week or two since the attack. 

 

The initial attack started before 7am. It was over 7 hours before they were successfully rescued. First to try to rescue them were special forces from the Yamam Unit of the police. These are the people who do hostage rescue and are the equivalent of SWAT. The first four officers arrived, and their protocol, when there is an active hostage situation, is apparently to burst in immediately. What they didn’t know was that the terrorists had come equipped with a huge amount of weapons, explosives and traps. They had placed explosives on most of the doors and stairs. The first Yamam officer was immediately killed. Their bomb disposal guy (if I understood the Hebrew term) was injured, and they had to retreat. More forces came but it was very slow work. In the end Ari and the police officers on the roof were rescued by forces coming up a fireman’s ladder onto the roof. 

 

The Sderot police station was in the news because of a standoff between the terrorists and army outside. The army brought in a tank fired shells, and at one point used an armoured bulldozer to start taking apart the building. The trouble was that it was known that there remained one police officer 2 floors down from the roof, holed up in a concrete space, and so they had to be careful. Otherwise the obvious thing to do would be to simply blow up the entire building on the terrorists. Eventually he was rescued, and Ari told me that the police station building doesn’t exist anymore (technically not completely true. You can see what remains in the photo below). 

Ari’s own emotional experience was also interesting. Throughout the 7 hours, he felt essentially no pain. He describes having come to terms with dying very early on – even as he hid behind the solar panels ready to jump out at the terrorists when they would come up onto the roof. He just assumed he wasn’t going to survive. It was only when he was rescued, placed in an armoured ambulance, and then transferred to the regular ambulance, that he feared dying - that he had come so far only to die on the road. 

 

The paramedic in the ambulance kept telling him to stay awake. He also heared her reporting on the radio that she was on the way to Barzilai with a critically injures patient, bleeding out and losing consciousness, and he remembered how scared that made him feel. Ari remained conscious until they pulled into the hospital, and he remembers being asked his name, and mumbling something in response, before blacking out.

 

He was taken immediately for surgery, where they found a bullet had hit his stomach (hence the coughing up blood) and also transected his pancreas. It had passed close to his vena cava (main vein returning blood to the heart) and had stopped short of his spinal cord. The second bullet went through his thigh into his buttock where it remains. 

 

The surgeons repaired what they could, and he later underwent two ERCP procedures (endoscope down throat into stomach to the opening of the bile ducts), to place stents into his pancreas and biliary system to maintain patency. 

 

Since then he has continued to improve and is looking forward to going home to see his toddler, and his wife (who he told me was pregnant although they hadn’t yet informed their family before the attack happened). He asked me if he would walk again, and while I deferred to the expertise of the orthopods for this, I did say that it seemed to me likely that he would. He has movement of his hip and knee, and only lost sensation to part of his foot, although he has significant neuropathic pain there. My understanding is that peripheral nerves can often re-grow, although do so very slowly.

 

At the end of his story, I feel tremendously privileged to have been a witness to all this. It felt as dramatic as any episode of Fauda, and I was struck by the incredible heroism of someone who when it all kicked off, instead of driving home, drove to a police station to arm up and go and rescue people.

 

 (I should say that my patient gave me full permission to tell his story, although you can see I changed his name and that of the police woman who died.

As a post-script there was an absurd moment where Ari’s dad, who was also at his bedside and asked me what I was doing here, started to tell me how heroic he thought it was that we doctors come over to help in the time of this war. I literally laughed at the incongruity of what he was saying, comparing doing what was essentially our normal day job in this reinforced ICU, whilst his son had just told us of literally being shot whilst saving others).

 

Clinical impact of the war / 24-hr on-call

I’ll try to make this post a little more coherent, and had some thoughts about how the war is affecting some of the clinical side of things here.

During my second day in the hospital they allowed me to do a  24-hour on-call, which to be honest I could see the ICU Head Nurse and some of the ICU attendings thought was too soon. I was also a bit worried, but calmed myself by remembering that Penn gave me a 24-hour on-call on my very first day there, and somehow that went OK. In the end the call passed without a hitch, and the head nurse was even complementary at the end, so with luck I’ll get to do some more. 

But to the question of how the war affected the type of clinical cases we see..

The most obvious way is the casualties directly related to the war: we have a soldier from an elite secret unit with a gun shot wound to the abdomen who had fairly complex abdominal surgery and procedures to fix his pancreas and intestines; a civilian who got shot in the jaw, and unusually got arterial vasospasm, suffering a stroke as a result (thankfully he’s recovering well from it); an elderly lady who was shot in the abdomen and also doing well; and a young man with a rifle bullet to his eye and chest (same bullet) who will also live.

But then there are the people with less direct injuries from the war. Like a gentleman with previous psychiatric history, who locked himself in the bathroom for several days, refusing to leave because he was afraid of the rockets raining down. Eventually he ended up with a severe life-threatening infection on the ICU, which in a sense wasn’t caused by enemy fire, but in another sense was.

In the third circle I’d include the people affected by how the war changes medical practice. So during my on-call I got a phone call from a colleague about a lady he wanted to refer to the ICU: a lady who had had a kidney stone blocking her urinary tract which then got infected. She had undergone a straightforward procedure to unblock the ureter in the OR, but now was becoming septic, had been re-intubated in the post-op recovery room, and had had an arterial line inserted, and he (or rather his attending) wanted her in the ICU. I went to assess her, and in the normal course of things I would have brought her to the ICU, especially as we had 4 free beds. However with the ongoing war and a risk of many casualties arriving at any moment, the calculus had changed. I had been instructed to be very careful about not filling beds unless we had no choice. So in the end I (and my attending) decided to manage her in the recovery room overnight, hoping that she would improve enough on antibiotics over a few hours to be extubated and sent to the floor, protecting our ICU beds. In her case this worked out OK, and the following day she was sent to the floor. 

Another similar example is to do with C-sections: There is an operating room next to the labour suite, used for cesarean sections, especially in urgent/emergent cases where you can’t take the woman all the way to the main ORs. However given the current security situation, the instruction came not to use that OR, and bring the women to the main ORs, irrespective of whether the C-section is urgent. I don’t know whether this is because we don’t want to lock up our staff far from the OR/ED/ER where they may be needed, or if the Labor Ward OR is outside the bomb shelter protection (I think it might be), and so the staff wouldn’t be safe. Either way, this is obviously less ideal for women delivering babies.

And on the topic of delivering babies and inconvenience, we now have very few deliveries at all in Barzilai. Most women have chosen, understandably, to drive further north to deliver further from the rockets. Whilst the labor wards in every Israeli hospital are in bomb-proof areas, I can completely understand that being a little further away is attractive, but that itself means being further from family, and has it’s own price. 

Moving away from clinical matters, our list of visiting VIPs continues to grow. After my first day catching a glimpse of Avigdor Lieberman, on my second day the president of Israel, Itzhak Herzog visited the ICU, with all his security entourage. I hesitated, but after one of the residents got a selfie with him I overcame my shyness and asked if he’d agree to be photographed with me. Later on, Yuri Edelstein, former speaker of the Knesset and minister of health, visited the ICU. He was actually a familiar face as he’s a friend of my in-laws in Hertzilia, and we had a brief but warm chat before he had to run off with all the top brass. Then today we had a delegation of the leadership of the Koran Hayesod who came from abroad to show the support of world Jewry.

That support, and the support I’ve experienced myself has been absolutely fantastic. I’m very grateful to all the friends from all over the world, and colleagues at Penn, who have reached out with such kind messages. I also wanted to say a particular thank you to everyone back in the community in Bala Cynwyd (Philadelphia) who have been so supportive of Ayelet and the kids. I still am in awe at how she manages to look after them alone, with everything going on, but the way that everyone has come out to help, with food and childcare and company, has been fantastic. So thank you from the bottom of our hearts.

1st day on ICU / the hospital routine at war

 (Writing this sleep deprived, at 4am during a 24-hour on-call, and still jet-lagged, so apologies for the telegraph-like speech and poor writing. Probably also a bit long)

First day in the hospital (Monday) was a nice easing in. Got to meet the anaesthesia department who were extremely welcoming.

Dr Duvdevani, the department chair, his deputy, and a total of 10 other anaesthetists had stayed overnight in the hospital as in-house on-calls, in case the inevitable ground invasion started along with flood of casualties, but thankfully things remained quiet. Those 12 in-house on-calls, got reduced to 8 on the following nights.

It turned out that the department chair is married to a good friend of my parents-in-law, which made for a nice personal connection.

All elective surgery since the big attack a week earlier had been cancelled, so there was actually relatively little work to be done by anaesthetists. That day they started one elective OR (skin cancer removal - yes, that is considered elective for medics).

We were visited by 3 paramedics and one doctor/officer from an elite military unit (not sure I’m supposed to name the unit), who came to get practice with intubations and airway management. This is very standard in Israeli hospitals, and I have personally trained several when I was in Hadassah (including Sayeret Matkal, Mista’arvim, Maglan, etc., as well as civilian paramedics) They need to be able to deal with medical emergencies as paramedics and army doctors, and Operating Rooms are a safe controlled place to learn. Although this time, with this war, their training felt to me a little more immediately urgent. Sadly with the lack of elective surgery they only got to help with one intubation.

I went and spend the rest of the day getting to know the ICU team, who were also very welcoming.

The ICU had gone though a lot of flux: On Black Saturday it got completely emptied, discharging patients to wards, that usually wouldn’t be sent out. It was immediately filled and overwhelmed with trauma cases as the hospital got inundated.

Then over the intervening week, most of those had gradually been discharged to the wards, so we were left with 5 patients, all but one of whom were injured in the initial Hamas attack. We are now working hard to keep beds empty, as a safety margin for when the war gets worse.

So when I got to the ICU, it was relatively calm, but they mentioned that one doctor was off in Miluim (emergency army service), and wasn’t answering his phone, and another one would be one of the 8 on-call anaesthetists that night, so couldn’t cover the on-call the following night. At the end of the Dr Jacobson (the ICU head of department) jokingly mentioned that I might be asked to do an on-call and I said “maybe, let’s see?”. At the end of the day things seemed to have gone well, and I asked if I could do it. He checked with the deputy medical director of the hospital (who happened to walk by that moment), got her "OK", and that was that.

During that day, Avigdor Lieberman came to visit the ICU. I kind of recognised him in the corridor but for a moment wasn’t sure from where, and did my usual head-bob of “I know you” acknowledgement when I'm not sure. He nodded back as if he knew me, but looked a bit puzzled too. He of course is a big-deal opposition politician, former minister of defence and minister of treasury, surrounded by body guards, and I realised I had never seen him before except on TV. He certainly had no idea who I was..

On the way home from work I stopped off at a supermarket from pita and humus for dinner. Whilst at the self-service checkout, a cashier called out “there’s a siren. Everyone follow me”. We all went quickly to the back office behind the store room and waited until we heard the explosions plus a few minutes, and then I headed back to finish the checking out. The machine didn’t even lose the items I’d already scanned, and just popped up the “are you done or would you like to continue message”.

On the way out I got to speak to a friend who lives here, and got the warmest, kindest message that really made me feel tearful. I’m really embarrassed to say this (but I will as I’m sleep deprived), but he told me that when he heard I was coming over, he decided to see what he can do to volunteer, and so he cleaned out his family home, and invited a family from Ashkelon to move in until the fighting was over. I honestly still can’t believe he felt that, because working here really isn’t any harder than the usual clinical days on any ICU, and I absolutely feel that just his action made this whole trip worthwhile. Separately, my mum has contacted the local hospital in Netanya, and has started volunteering there in a medical capacity. I’m honestly overwhelmed by how volunteerism seems to be feeding on itself throughout this. Almost like a snowball, with people helping each other.

After that I went home to a house lent to me by friends of the my parents who are currently in Jerusalem. The place is beautiful, and <10 minutes from the hospital, with a small bomb shelter inside it, so is perfect. I had a bite to eat and went to bed.

Sleep was fitful, but no sirens woke me. Just jet lug. Headed a number of booms of distant explosions, and briefly worried why I hadn’t heard an air raid siren, but realised that it was just very precise and only sounded in areas likely to be hit.

Woke in the morning to shower, drive to work, and get started on 24-hour ICU on-call.

On the way found driving to be an odd experience: you keep trying to spot placed you can park and run for cover in 30 seconds. It adds a little stress the usual defensive driving of looking out for cars trying to do stupid things, and is not something I usually have to think about.

Landing in Israel

 I hope this is OK, but I thought I’d keep some sort of diary of the time here in Israel. I apologise if this is a bit of a stream of thoughts..

There are a lot of doctors abroad who are hoping to come to volunteer in Israel, and I feel really lucky that Barzilai Hospital in Ashkelon had a place for an anaesthetist/ICU doc, so on Saturday night Ayelet and I found a place on one of the few flights to Israel and I managed to come here.

The flight was an interesting mix of people: The guy behind us in the queue was a volunteer for the army who 10 years previously had volunteered as a lone soldier in the paratroopers, and was now coming to join his old unit on the Lebanese border; In front of us were an elderly Haredi couple on their way to a wedding.

Friends of my in-laws had been collecting equipment for soldiers (socks, clothes, leathermen, etc.) and gave me 4 bags full. I honestly thought airport security would have an apoplectic fit, but they took it in their stride and let me board with all 5 bags.

We landed safely in Ben Gurion, where everything looked normal except that all the airplanes I saw were ElAl, plus one what looked like a US Air Force transport plane. My mum came to pick me up which was wonderful, and my grandparents-in-law had lent me their car. Everyone here is being so generous. While we went to pick up the car in the car park, I got the first real indication of the situation here, as the air raid sirens went off. We were thankfully 2 floors down, so sheltered in place, waiting for the explosions to pass plus a bit for any falling shrapnel, and went back to the car.

That night I got to stay with my parents in Netanya, having had a wonderful meal dad had rustled up at zero notice as usual. Woke at 4am to head south - the roads south of Tel Aviv were wonderfully empty.

The Fog of War

During a recent on-call I found myself facing whole string of confusing questions that I felt crystallised some of the difficulties we are all facing in this part of the world.

I was in the trauma room when a call came in that the army was bringing in someone who had been shot multiple times and was unstable.

I call my team of anaesthetists and we gathered to prepare for the case. Within a few minutes a 20-something year old Arab man was brought in on a stretcher. He was conscious but drowsy, and his lower body was covered in blood, with battlefield tourniquets applied to his legs. The trauma team worked on him quickly, assessing, putting in “Hi Flow” IV lines, starting the Massive Blood Transfusion Protocol with uncrossed blood, intubating when he became more unstable, and eventually taking him to the CT scanner, and then to ICU with surgery. 

Without going into too many details, I was interested to hear the medical team start to hypothesise about the mechanism of the injury whilst we were waiting for the CT. He had at least 3 bullet wounds, and some of the team thought they may have come from behind, some from below. This last bit was particularly unusual as they said that usually bullets on lower parts of body come from above (think of a rifle pointing down at someone’s legs). I suggested perhaps a ricochet from a rock, and they agreed this was possible. 

After we got back from CT, I found myself chatting with the soldiers who had accompanied the patient in, and they gave me roughly the following story (which of course I have no way of verifying). I’m also filling in details from what I understand from things they implied:

They are part of a semi-elite unit. There have been a number of recent incidents of terrorists throwing explosive devices at civilians in this area, so the army acted to stop it, setting up an ambush from two positions.

They have strict rules over when they can fire: They must be 100% sure that this really is a terrorist, generally even having to wait until after he threw the bomb and it exploded, before they can open fire.

He threw his device and then tried to run, at which point they shot from two angles, hitting him in the crossfire.

Even though he was already trying to get away, they had to shoot, because these attacks have been happening again and again, and if they didn’t get this guy, he and his friends would come back and do it again.

When I said that I might read about all this in the news they said “possibly not” – that to avoid civilian anxiety, the army doesn’t always publicise such incidents.

As the night wore on (and it did drag – I got 1 hour sleep in 27 hours) – my mind started filling with questions:

• Why had I not heard of these repeat attacks? Is it really possible that the media doesn’t pick up on it? – in Israel the journalists understand the need for national security, so it could be.

• If the guy threw a bomb, wouldn’t the civilian target have been hurt? Or at least hear it? – but perhaps this time he got scared and threw it at the soldiers.

• Am I OK with the idea of soldiers shooting terrorists who are trying to run away? Am I OK with them *not* shooting terrorists just because they have completed their attack?

• Isn’t it a stupid rule that they have to wait until *after* the bomb explodes before they can open fire?

• But if they don’t wait, how can we know this is really a terrorist, and not some guy in the wrong place at the wrong time?

• Do I believe them that they shot a real terrorist? Could this all be a case of mistaken identity?

• Why is he in the custody of this combat unit anyway? Don’t military police usually guard terrorists after they have been shot and captured?

• Did they hesitate before saving his life? There is no doubt that without the medical treatment they gave in the field he would have died.

• What’s going to happen to him after we finish our medical care? Prison? Interrogation? Do I have a problem with that, if it may prevent future attacks?

Thankfully for me all these questions remained purely academic. As a doctor I am in the privileged position of not needing to worry about all this. We simply provide the best medical care to the best of our ability, saving whoever we can and without needing to make any judgements.

As an Israeli citizen I am more troubled. I found myself flitting between wishing the soldiers had acted more humanely (did they shoot an escaping man?) and more aggressively (who waits for a terrorist to bomb a civilian before acting?). Perhaps my confusion means they got the rules right.

Then I eventually found a moment of clarity:

Yes this is horrible and confusing and has no correct answer. But that is because the situation is horrible and confusing.

As long as we have our civilians living in the West Bank, inside a population who doesn’t want them there, we will need (semi-)elite soldiers to ambush terrorists. And this will be messy.