ICU Care : Marathons, PTSD and War

This last week has felt pretty extraordinary, although perhaps Israelis are used to this. Still I thought it might interest some of you, or my future self, if I wrote something down.

Start of Tel Aviv Marathon

The week started peacefully with the Tel Aviv Marathon on Friday. A friend in the department had invited me to join as part of the “ALS” anaesthesia medical teams, the closest I’ll ever get to a Marathon. My team (myself, paramedic, EMT, and Bat Sherut) treated two patients with very different illnesses, both stereotypically Israeli:

The first was classic heat stroke. Young man came in drowsy and confused. We measured a core temperature of 40.2 C, and rushed him into the waiting pool of ice-filled water. Within a minute he woke up, and after 3 minutes we pulled him out, having placed an IV line in his arm and with a core temperature now “only” 38.7. He continued to improve, and once stable, sent him to hospital in an ambulance.

The second patient I thought was the same story: agitated, confused and combative, fighting people and needing to be held down in chair as he was rushed in. Then his brother whispered in our ears the words “combat shock”, and later that he had been a Navy SEAL (Shayetet 13) and now had PTSD. We shooed away the onlookers, and told everyone to go in their booths and close the curtains. 

I’m hugely impressed with what Maya, the young paramedic did next: She completely took control, including throwing out the medical director. Talking calmly to the patient, she introduced us all and explaining where he was. She offered to move his seat so his back would be to the wall and he’d feel safe and he gratefully agreed. He was still very agitated, and I realised later, kept reaching for an imaginary hand-gun on his right hip. The ED medical director sent someone to tell me I should sedate him so we can measure his temperature and start treatment. Maya talked me out of it, I listened, and she kept talking to him. Soon she was offering him salty soup and had him laughing. His heart rate dropped to the 120s, then 110s. He would still suddenly jump, but she calmed him and started tapping him alternatively on each shoulder – a trick she explained help calm PTSD patients.

Eventually I was able to discharge him home, without even going via the hospital, and Maya got a glowing praise.

Ward in Level -2 at Ichilov (from Tiimes of Israel)

The following morning, Saturday at 08:15, the air raid sirens sounded. We all rushed to our bomb shelter (“Mamad”), and I immediately turned on my phone (usually off over the Sabbath). The war with Iran had started. I soon saw texts from the head of the General ICU, asking all the intensivist attendings to come in, and I quickly got dressed in scrubs, and drove fast into Ichilov Hospital, on the way noting cars with Magen David emergency service bumper stickers heading into the city. Once there I was sent to the Neurosurgical ICU, where we downgraded what patients we could, and I helped direct the  transfer of our remaining ICU patients to newly cleared underground PACU area that became our home for the foreseeable future. There were the occasional hiccoughs, like 5 porters being sent at the start before we had the patients ready, and then all leaving before we could use them; a ventilated patient being stuck on Level 3 because they had been taken out of the lift due to an incoming rocket alert, and then having to wait there for over 30 minutes as all the lifts were occupied; insufficient functioning travel ventilators, and eventually me just bag ventilating a patient so we can get them downstairs. All this of course while air raid sirens were going off intermittently. But overall, I was pretty impressed with how fast and smoothly it all worked out. Within a couple of hours the NeuroICU on Level 5 was empty and all our patients safely underground.

The next impact of the war has been the large call-up of many reservists. We have a particularly high proportion of anaesthetists serving in the armed forces and special units in particular (perhaps the highest proportion in the country) and suddenly there were holes in the on-call rota. I got a call asking if I could move forward my first-ever overnight ICU on-call, to cover one such “puncture”. So now, thanks to the war, I spent Monday working 26 hours in the General ICU, having never worked that unit before, in an underground location that the nurses had also only worked in for 2 days. We had patients on ECMO with unstable AF, a double pressed patient on 100% oxygen + iNO with unclear diagnosis, a tracheostomy to place bedside, and the usual set of ICU sick patients. I remember during a free moment I went down to Level -3, to see where the non-ICU wards were. I found myself in the paediatrics ward: rows of fairly tightly placed beds and cots, in a large underground car park. The floor was made of that slightly shiny floor you sometimes see in acr parks, and there was a hubbub of voices of children and adults. It felt surreal to see families effectively living here, deep underground, like in some post-apocalyptic Hollywood movie.

The rest of the week has been spent working as the intensivist on the neurosurgical ICU, a tight-knit unit I am growing to love. We are still getting several air raid alerts each day, but being as we are 2 floors underground, we just continue work as usual. The one exception was this morning: I took a young officer who had had a seizure for an MRI scan, and who was still agitated so needed sedation to lie still. We got him into the scanner, and before I pushed any drugs, the air raid siren went off. I and the MRI technicians quickly wheeled him out of the scanner, down the corridor into the main building, but there was no way we could get him underground in time. The technician told me “I can’t stay, I have children” and hurried off to the underground shelter, leaving me alone with the un-sedated, but still critically ill, patient, in the middle of corridor, and with an ethical dilemma. I sat down on the ground, and waiting it out, called Ayelet for a chat to pass the time (she asked if I’d mentioned to the technician that we also have children – I hadn’t). A friend had told me that at another, private, hospital, they had been doing IVF procedures under anaesthesia/sedation in above-ground ORs. Whenever a rocket would head their way, the gynaecologists, nurses and lab technicians would do what we are all meant to do, and head to shelter. The anaesthetist stays with the patient. It is logically right, minimising potential casualties, but I also have a little pride that my specialty is the one to stay with the patient, caring for them whatever the situation.