LOOKING AROUND : Experts in tragedy

By Barbara Sofer
Feb. 27, 2003

A month before September 11, Jerusalem trauma surgeon Avi Rivkind was lecturing about terror medicine in Belgium, of all places, at an international medical conference.
"When they heard the topic, the Americans walked out to grab a cup of coffee," says Rivkind, his pugilist's face lighting up with its familiar ironic smile. "To them, our subject was irrelevant. Left in the room were doctors from Belfast, from India and us Israelis." Ironically, over the past the last year and a half, Rivkind, chief of surgery at Hadassah University Hospital, has been interviewed on tens of television shows in America and Europe, describing treatment of terror victims and how he has treated terrorists themselves. The latest, CBS History Channel's "Inside the mind of a suicide bomber," traces suicide attacks from Japanese kamikaze planes which killed 5,000 American sailors to today's disease-infected human bombs usually aimed at Israeli civilians. It's with these that Rivkind has had such up close and personal acquaintance.
"We're ahead of 99% of the medical centers in the world simply because we've made an effort to prepare," said Shmuel Chaim Shapira, the avuncular professor of medicine specializing in such nasty subjects such attacks of plague and nerve gas. Shapira serves as deputy director general of Hadassah University Hospital in Jerusalem and is a reserve lieutenant colonel in the Israeli Defense Forces.
"From Zion will go forth Torah." This isn't exactly what was meant. Nonetheless, we should feel satisfaction in being primed for what we may have to face any day now. Preparation means planning and practice and more planning and practice.
"Who is wise? He who can foresee the end product," says the Talmud. The end product, no matter how grisly. According to Shapira, there are protocols for "every conceivable threat and a few that are inconceivable. We have to remember that a terrorist's imagination is more ghoulish and diabolical than ours."
Elements of potential attacks are biological, (anthrax, plague, smallpox, Ebola and tularemia, an animal disease transmitted to humans by insects and ticks), chemical (nerve gas, mustard gas and paralyzing botulinum toxin,) and radiation (so-called dirty bombs conventional explosives with radioactive substances mixed in) and combinations of the above. All of these may be added to our continued struggle with conventional warfare. Nails and bolts soaked in rat poison, terrorists' blood found to be infected with hepatitis B and AIDS; these are still considered "conventional." AS THOSE of us at home have stockpiled drinking water, Magen David Adom has been putting aside extra blood. Hospitals have purchased walkie-talkies, (back to basics if other communications fail), ventilators, outdoor showers, antidotes, antibiotics and disposable IV's. First-response medical staff have quietly been vaccinated for smallpox. In Jerusalem, there are check-lists and flow charts and color codes for each type of demonic attack. "In such a mass casualty, God forbid, medical and paramedical staff will be reassigned quickly according to specific plan," says Prof. Shapira. There have been multiple drills for managers and full-scale simulation for the entire staff. I was present for one of those trials a few weeks ago. The imaginary scenario was a wedding hall attacked by terrorists. The make-believe guests rubbed their eyes. Could be nerve gas, said Shapira. Could be ammonia.
Picture it. Kennedy Square at Jerusalem's Hadassah Ein Kerem hospital is very crowded in normal times. Since June, the usual flow of patients, staff and taxis has been complicated by the construction of a $28 million dollar emergency room equipped for nonconventional warfare. In the past couple of weeks, the pavement has been dug up to strengthen the hospital's prodigious security.
Could the hospital really be a target, we might ask with incredulity. Remember that the highest casualty tragedy in modern Israeli history remains the attack on the Hadassah medical convoy on April 13, 1948. Seventy eight men and women were murdered, including the hospital's director general Prof. Haim Yassky. After the Six Day War, Jacques Chagall was asked to repair his famous windows in the hospital's Abell Synagogue because the originals had been bombed.
Add to the busy scene, a simulated attack, with medical and support staff gathered outside, ambulances and soldiers in jeeps. Because of the bitter cold, soldiers were excused from using the outdoor showers. On one hand, the scene felt surrealistic. On the other hand, my shivers went beyond the chill of the icy southwest wind. Like every Israeli, I know that the unbelievable has a way of fast becoming reality here. During the exercise, the younger doctors had a hard time keeping a straight face as dummies were lifted out of the ambulance. After all, they've had two and half years of genuine mass casualties to improve their skills. Nonetheless, they all did their jobs. Practice, we know, might not make perfect, but it does help. Hadassah doctors and nurses say that an unsettling part of dealing with terror attacks is how calmly and quickly they slip into their routines. Unsettling or not, that composed professionalism has resulted in the saving of many lives.
In the early morning of November 21, an Egged bus carrying students to school was blown up in Kiryat Menachem. Eleven people were murdered, and tens of others seriously injured. That night, the terrorist's father went on TV and praised his son.
The following day, two things happened. The terrorist's father was brought to the very same emergency room with chest pains. He was cared for by the same medical staff who had labored over his son's victims the day before. On the same day, 70 physicians arrived in Israel from the US to take part in a medical conference. Standing in the hospital lobby, the American experts listened as a cardiac thoracic surgeon explained how a young woman, 23, with a wristwatch lodged in her throat and both carotid arteries severed has survived the bus bombing. Silence.
"We all realized that in our own medical centers, that patient would likely have died," explained Harvard Prof. Ben Sacks. "We were humbled. The Israelis have moved far ahead of us in preparedness." I don't underrate faith and prayer. We recite Psalm 121: "The Guardian of Israel will neither slumber of sleep." But our efforts, what is called hishtadlut are required, too. In our preparation for one of the most critical periods in modern history, we have to let the coffee breaks wait.