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.