It’s a scene that has become all too familiar in Israel – a terror attack in a crowded street in Haifa, northern Israel. Women still carrying their shopping bags are strewn across the pavement, their limbs unnaturally askew. A man lies face down nearby, with twisted shards of metal sticking out of his back.
Within minutes, the first ambulance arrives. An organised mayhem ensues. Paramedics fan out, tagging the dead and wounded, administering the first life-saving treatments. Police explosives experts scour the area, checking for further bombs, creating a perimeter and clearing a path for ambulances through the traffic.
On closer inspection, the dead bodies turn out to be dummies or actors. After being checked by paramedics, several of the injured get up and start chatting with onlookers, the shards of metal sticking out of their backs revealed as pieces of plastic.
The drill is the finale of a NATO training course for mass casualty incidents at the Rambam Medical Center in Haifa. Leading doctors and healthcare officials from a dozen countries including the US, Czech Republic, Finland, Georgia, Russia, Croatia and Jordan have spent three days with Israeli experts whose skills have been honed by constant war and countless suicide bombings.
Rambam Medical Center has been training foreign doctors in mass casualty incidents since it was first approached by Latin American diplomats in 1999. In the past decade, hundreds of physicians and health officials from more than 50 countries have learned from the experts in Haifa. Similar courses are run by hospitals throughout Israel.
“We, because of our history and because of the situation, plan in advance what to do during mass casualty. We had to do it more than a few times, and correct our thinking after each time. Every hospital has standing orders. Every hospital is experienced in doing it,” says Dr Moshe Michaelson, director of the emergency and trauma units at the centre.
“We share our knowledge, we share our experience because we think these things will happen in your countries and in our country again and we think that being prepared for any kind of mass casualty, any kind of disaster is very important,” says Michaelson.
This workshop, teaching trainers to pass on the skills in their own country, costs €35,000 for 30 participants. The funding comes from NATO. Michaelson says the payments barely cover the costs.
In January, the Israeli Health Ministry and the World Health Organization hosted the world’s first international conference in Tel Aviv for emergency preparation and response.
There is no central body coordinating the growing number of foreign doctors coming to learn from their Israeli colleagues, but most spend a day at the Israel Center for Medical Simulation at Sheba Medical Center – a pioneering facility where physicians can “operate” on smart robots that talk and react like human patients – and then watch videos of their work with trained instructors. The centre can simulate a range of medical nightmares from shooting attacks to a full-scale bio-chemical assault.
Rambam is the front-line hospital dealing with war-wounded from Israeli military operations in Lebanon. Since 2001, Rambam has also been the major trauma centre for dozens of suicide bomb attacks across northern Israel. In the summer of 2006 it faced the challenge of treating hundreds of victims of massive daily rocket attacks by Hezbollah, some of which almost hit the hospital. Michaelson says that produced the toughest day of his career – 150 casualties in a 24-hour period as the rockets fell. Preparedness of Health Systems, Guidelines for Mass Casualty Situations, by Michaelson and colleagues, is now a standard training manual for NATO medical teams.
“We had our own war,” says Sandra Elisabeth Roelofs, First Lady of Georgia, who is a trained nurse and attended the closing ceremony of the NATO course. “Unfortunately you have to prepare for mass casualties. This is not an art. This is based on knowledge and experience.”
Professor Eric Frykberg, chief of general surgery at the University of Florida College of Medicine, Jacksonville, Florida, says the training is vital. In 1983, Frykberg was in a mobile military surgical team aboard the USS Iwo Jima off the coast of Lebanon when Shi’ite suicide bombers rammed a truck full of explosives into the marine barracks in Beirut, killing 299 French and American soldiers and injuring 75. “I was a year out of training. There were only six of us that took care of 65 casualties inside six hours. We sat back and realised: we don’t know this stuff. This is totally different. We don’t learn it in medical school. It wasn’t in residency training.” says Frykberg.
He says the Israelis are years ahead of most other countries because they have learned that in a major emergency, hospitals cannot cope with a sudden influx of critical patients simply by speeding up regular procedures. “I see 450 trauma patients a month and we do a very good job of taking sometimes two, three, four at a time on a busy Saturday night. Sometimes 10,” says Frykberg. “But suppose all those 450 patients suddenly showed up at your door within an hour? That’s a whole different ball game.”