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.

The Shalom Question, the answer, and Hebron

A few months ago a friend (Shalom) asked me what I started to call “the Shalom question”. We were talking about people drifting away from Judaism and the Jewish people, and what, if anything, could convince them to stay. He suggested, as a religious Jew, that he always ended up having to invoke God in some way, and that that was not convincing to someone who didn’t believe. I very much wanted to believe that a convincing reason could be found, that didn’t require faith.

Well, recently I have been reading a book by Jonathan Sacks that has gone a long way towards answering this question for me. He talks inspiringly about how Judaism brought concepts of justice and valuing human life to the world, which, combined with the undoubted achievements of several famous Jews, seems a reason to keep this group going. After all, if we made such a difference to the world in the past, who knows what other contributions may be just round the next corner?

But then I hear this little voice in the back of my head. Every time I read an inspiring line about some important contribution to social justice or individual morality, this voice said “but is that really how things are now? Are we really that moral?”

And then I saw this video of what happened last Thursday in Hebron

( http://www.btselem.org/firearms/20160324_soldier_executes_palestinians_attaker_in_hebron )

People will say that every group has some bad apples, and that the soldier who murdered the unarmed terrorist was immediately arrested and condemned by our leaders.

But the thing is that you see no one around very concerned. Not concerned to provide medical assistance to the injured terrorist, and not surprised or concerned when a soldier points a gun and kills him in cold blood. Here are about a dozen randomly chosen fellow Israelis, and not one objected.

So how am I supposed to believe that somehow we have this high moral standard? Based on this random sample, I have to conclude that a large number/majority of us have no problem with murder.

In his book Rabbi Sacks says the following[AK1] :

“Sholom Ache once thanked God that his people have not been given the opportunity to commit against others the crimes that had been committed against it. Perhaps every nation, once it has power, abuses it.”

Rabbi Sacks however, goes on later to say that he believes that, in the guise of Israel, Judaism will finally be able to put into practice all its moral principles for a good society that for 2000 years remained just theoretical.

I am sorry to say that is not what I am seeing. It seems like we have headed much more down the path warned of by Ache, and by Yeshayahu Liebovitz:

“[Control of the Arab population] will undermine the social structure that we have created in the state and cause corruption of individuals”.

I see no immediate solution, even if I have some ideas.

But for now, whenever I read inspiring lines of text such as Rabbi Sacks’, there will remain a quiet voice of doubt in the back of my mind that we are not such a moral light to the world.

---

 [AK1]p.97

Fortress OR

I am just at the end of my first day/24-hour on-call in the new operating rooms at Hadassah, and after the initial confusion and getting lost, which will probably last for a few months, I started to be struck by a few differences between here and how I imagine a typical OR area would be back in the UK.

Just to give you a sense of the place, it feels huge. I don’t actually know how many ORs we have there (I was doing urology in OR 46, but I think they start at 30). Each OR is large and airy, with multiple flat screens where I can project my anaesthesia monitor, or a live video of the surgery. The ventilators are state of the art, and my anaesthesia trolley contains 90% of the drugs I need, saving my lots of running around. The patient bed seemed so complicated I felt I needed a manual just to work out how to tilt it. It sets of an alarm if it thinks part of it may collide with something, and asks you to press again if you are sure you want to continue.  At one point it decided the right leg was going to hit something (not sure what), and the left one was clear, so it simply split them and lowered one only. I can see we are going to have a few disagreements, but hopefully in the end we will grow to understand each other.

The place is a maze. There is the same grass-green stripe along all the walls, and you really get little sense of where you are, or how anything is related to anything else geographically. I spent a crazy amount of time walking randomly around sometimes returning to where I started, looking for a particular spot (e.g. the OR where I left my patient).

But putting all that aside, I think with a very little investment of time on my part, I will grow to love the place. It feels so much cleaner and more modern than the old ORs.

And then, sometime around 1am when a friend was giving me a tour of the place, I started to notice some of the things that perhaps would not have been seen in the typical NHS Operating Room suits.

Firstly, we are level -4. That’s not a random decision: every Israeli OR needs to be in a protected area in case a rocket siren sounds in the middle of surgery – you can’t very well evacuate the patient in the 90 seconds before impact.

Then I started noticing the doors in the corridor. They are thick steel, with those twisting door handles that drive bolts up and down into the steel doorframe. I found one small corridor between the Recovery Room and the Family Waiting Room with 4 such blast proof doors, spaced roughly every 2 metres.

That started to feel a little strange, but after touring the ORs, we went upstairs (still 3 floors underground) to the on-call rooms and offices. Here the doors were normal. You know, with a normal handle and that thin vertical glass window extending most of the length of the window. The doors were painted metal, which is not unusual in Israel. And then I noticed a curious effect: when I looked through the window from afar, it felt a little like a fisheye lens. I first thought how ingenious this was: you could see someone approaching the door from afar and not push it open into their face. But then I noticed the effect became less as you get closer (which sort of defeats the object), and that there was a slight yellowish tinge to the glass. Then I realised when I had seen this before: it was looking at an angle through the windscreen of a VIPs bulletproof car in the UK.  I may be wrong, but I think someone may have put bulletproof polycarbonate glass into the doors of the anaesthetists’ offices.

Then there were lots of other little surprising touches we found as we explored. Such as the fully working shower-heads in the middle of a corridor (Nuclear, Biological and Chemical decontamination), and what looked like air filters (perhaps for the same reason).

That evening, some of the nurses had returned from a conference where a drug rep had brought food, and they kindly shared it with us in the staff room on level -3. Afterwards some of the people said they were going out for a smoke, and mentioned that there was a staff smoking area nearby. I asked about it (no, I don’t smoke, but I was curious) and was shown to the open window, where you could look down into a pleasant paved courtyard with garden benches. This was around midnight, so I can’t tell if the darkness was natural, but I realised that the courtyard must be 4 or 5 levels underground. I craned my neck upwards but could just see building all the way up. I still don’t know if the top of this void in the middle of our building is concreted at the top, or is open to the sky, but it looks like it would be a difficult trajectory of a missile to enter. I pulled my head back in, and as I closed the window I noticed that it too was in a blast-proof steel frame, with a thick steel shutter you could draw across.  

I don’t now entirely what to make of all this, and would love to chat with the seniors in the department to find out more. It seems overkill if you are trying to defend yourself against the not-uncommon missile bombardments from Gaza or Lebanon (these happen every couple of years). I have wondered if it was nuclear bomb proof, which is not as crazy as it sounds – most of us assume that Iran will get the bomb in the nearish future, and I have been told that the ICU at Rambam hospital in Haifa is in a nuclear bunker. Or maybe it is somewhere in between – I am not expert enough to know if the Scuds of the type fired by Iraq on Israel need this type of protection.

What is certain is that the hospital planners here have some extra dimensions to consider that the NHS management perhaps don’t.

Finally, something on the BBC about Israel that is not about the Israeli/Palestinian conflict

Just heard the BBC news podcast where they "discovered" that Israel was deporting refugees against their wishes to 3rd party countries.

Ignoring for now that this is hardly a discovery: it has been a matter of public record for ages, and worrying for those of us who care about Israel, but paraphrasing Abba Eban "Israel rarely misses an opportunity to miss and opportunity".

We could have shown the world a model for how to care for refugees. For relatively little social or financial cost we could have absorbed them, provided education and security, and offered them to stay or move and develop as they wished. We even have the infrastructure for immigrant absorption up and ready, with Merkazai Klita, government funded language courses, university discounts, etc.

And the risks would have been so low. We have built a strong barrier in Sinai against more coming, so such simple kindness would not have encouraged more arrivals.

Unlike potentially hostile Syrian refugees the Eritreans clearly are not.

But instead of doing our international duty, and doing what is right in our own eyes, we treat them and continue to treat them terrible, and now we get even worse PR.

When will we learn?

http://www.bbc.co.uk/programmes/p03hfg20

For what am I apologising?

This evening the ambulance brought in a 10 year old boy from one of the refugee camps around Jerusalem. He had been shot in the eye by a policeman with a “sponge bullet” and, according to the news report I read later, was in a Moderate Condition (“Matzav Beinoni”).

“Moderate Condition” apparently corresponds to complete destruction of one eye, numerous facial fractures, and a fracture into his other eye.

We intubated him, took him to the OR, where over several hours the surgeons removed the remnants of his eye, fixed and plated a bunch of bones, and brought him to my ICU sedated and ventilated.

I have just finished explaining to the family that his eye has been removed. That he would never see with that eye again. I had to explain it three times, as they went through the naturally difficult process of accepting what had happened to their child.

I tried to soften it by saying that we think we have saved the other eye. That, thank God, he didn’t suffer brain or spinal damage. That tomorrow we hope to wake him up.

And then, I said “I’m sorry”.

To this very moment I’m not sure for what I was saying sorry.

Was it the “sorry” that we were taught in England was a natural way to show sympathy for a patient receiving bad news?

Was it a “sorry” that we couldn’t save his eye?

Was it an apology-in-absentia for the policeman who felt justified in shooting a 10 year old in the face?

Was it a communal apology, on behalf of all Jewish Israelis, for having put that policeman there? For having put the kid in the refugee camp? For almost laughing at Ayelet’s question “was it a Jewish or Arab kid” (who ever heard of a Jewish kid being shot by a rubber bullet in the face?).

I want to blame someone.

I thought about blaming the boy, after-all perhaps he threw stones at the border policeman. But he is a 10 year old, and 10 year olds do stupid things, and should not be punished with gunfire.

I thought about blaming the policeman, but he was possibly facing kids throwing real rocks. He was probably told to guard a particular spot, and had limited ways to deal with the situation.

I considered blaming the family. Shouldn’t they have kept an eye on the boy better? Shouldn’t they have taught him that policemen with rifles are dangerous? Maybe they brought him up to be violent. Who knows? But I can’t blame the grieving parents of a kid who was just coming home from school, my have done something stupid, and will now be disabled for life.

So I have to blame The Situation. The situation where we put paramilitary policemen in close contact with kids. Where we justify the frequent use of violence as being the only way we can assert control, without stopping to think whether we should be there at all. Where most of us will never have to come face to face with the consequences of us blindly letting The Situation continue.

Perhaps I am apologising for my part in that, and for having failed to do anything to improve matters.

Big news!

Rather than my usual musings on Israel, this time I have some personal news.

On Friday I asked my girlfriend, Ayelet, to marry me, and she agreed!

I know that a lot of our friends and family in the UK haven’t yet had a chance to meet her, and I was wondering how to summarise her here in a couple of sentences. Of course I can’t, but I thought I’d string together a few facts just so that you have some image of her.

Ayelet is an Olah Chadasshah (new immigrant like me), who moved from New York to Israel a couple of years ago. She’s a wonderful, caring person; connected to her Judaism, her family and her new home. She speaks Hebrew, Chinese and we are working on teaching her English too!

She also very much enjoys exploring the countryside, and on Thursday we went camping in Wadi Tzin, next to Sde Boker in the desert. On Friday we did the 16km hike up Chod Ekev, with the difficult climb up the side of the valley. I’d forgotten quite how scary the slope could be (at least for someone with my fear of heights – see photos), but somehow we got to the top and enjoyed a spectacular view across the desert.

The climb to Chod Ekev

The top of the mountain

At the summit I asked her if she’d marry me, and to my joy she agreed!

I’m sorry that we didn’t get a chance to contact many of you immediately, but we were racing the sun to get off the mountains before dark and the Sabbath, and then spent the next two days in a gorgeous hotel called Beresheet overlooking Machtesh Ramon. It was one of these places that really pampers you, with massages and private swimming pools and fantastic food. They are also right on the edge of the desert, so wild ibexes jump the fence to drink from the pools and one of them came and ate our left over carrots and cucumbers from the hike, from our outstretched hands!

We’re now back in Tel Aviv. Life seems a bit of a daze but we are both very happy and very excited at the thought of the upcoming adventure of life together.

Why does it have to be like this?

I have a patient who is only 52 years old and will die in the next few hours. I spent most of the night doing everything I can to extend his life just enough for the family to get here.

At 11pm I spoke to his brother who said he can arrive by 2pm from Ramallah, but unfortunately, because of the situation at the Kalandia Checkpoint, may not be able to arrive sooner. He did however managed to contact the patient’s teenage son who was nearby and who I spoke to this morning.

I can’t even begin to imagine what this boy is going through, trying to deal with the fact that his father is dying, but he managed to put on a brave face talking to me.

When the boy realised how bad things were he asked if there was anything we could do to try to help his mother get to his fathers bedside before he died. The trouble was that she doesn't have a permit to get through the checkpoint.

After I went this them to Hospital Reception (me as a doctor being there may open some doors), we ended up having to just give the teenager a letter saying that his father is a patient at Hadassah and is dying. He now has to take that to various bureaucrats to get the permit. I hope and pray that someone helpful decides to rush it through, because my greatest fear is that while he is off doing this, his father will die alone.

It doesn't need to be like this.

There should be a number I can call for the officer at the checkpoint. A helpful army soldier should pick up the wife and drive her straight to us. Doors should part.

If not, then I'm not sure the son will ever forgive the occupiers, and I'm not sure how easily I could forgive us either.