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 7th 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 7th, and are rapidly building further experience there.
Then there was the patient who drove a “Tractoron” (maybe Quad bike?) on Oct 7th, 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 29th.
There was a man who went fishing on the coast on Oct 7th 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 28th. 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.
