Jerusalem's Hadassah Hospital helps US prepare for mass casualties

By Joe Charlaff

Never before has emergency preparedness been so vital, especially in Israel. While fire, EMS, law enforcement and the military are prepared to meet the threat of terrorist attacks, Israeli hospitals, too, have to be well organized to deal with a sudden influx of large numbers of casualties.

By 2001, at the height of the intifada (Palestinian uprising), when terror attacks in Jerusalem were being perpetrated almost daily, Hadassah Hospital in Jerusalem's suburb of Ein Kerem had gained considerable experience in handling mass-casualty events and terror attacks.

The Hadassah Medical Organization is one of the world's leading institutions in healthcare and includes two hospitals, five schools, outpatient clinics, research facilities and community health centers. The system treats more than one million patients annually regardless of race or religion, and in 2005 was nominated for the Nobel Peace Prize

A temporary emergency room, in a tent on Hadassah Hospital’s grounds, during a July 2007 terrorism exercise staged at a major soccer stadium in Jerusalem. During this joint exercise with Magen David Adom, once the simulated injured were "treated" on the scene, they were evacuated to this location, so as not to disrupt the regular emergency room in the hospital building. (Photo credit: Avi Hayoun)

As direct result of 9/11, seeing that American hospitals and their staff were totally unprepared for an event of that magnitude, Hadassah felt a need to share their knowledge and experience with their counterparts in the U.S. and other countries.

The birth of cooperation
A senior surgeon in the hospital’s trauma unit initiated the idea of a program of mass-casualty and terror workshops and inviting American medical staff to participate. The idea got an additional boost as a result of a request from the Israeli Embassy in Los Angeles on behalf of medical staff in California who looked to Israel for guidance in this area. And so in July 2002, the week-long program of workshops got off the ground.

Since then, Hadassah has been running their Terror and Mass Casualty Event workshops, which provide a comprehensive overview of the principles of terror medicine, mass casualties and disaster management, building on the extensive experience gained by Israel in dealing with victims of terror attacks.
 
Typically the workshops are attended by medical staff and by policy-makers, such as heads of hospitals and politicians. Attendees came from the U.S. initially, however subsequent participants also came from Australia, Europe and South America.

Workshops are scheduled twice a year, in February and July, but if a group of more than eight people puts in a request, an additional workshop will be organized.
In addition, Hadassah runs the workshops abroad for organizations including the FBI and the Department of Homeland Security. The average attendance when groups are hosted by Hadassah is 20 people, but when they go abroad, attendance can be a few hundred.

Workshop topics include "Principles of Mass Casualty Management," Pre-Hospital Strategy," "Chemical, Biological and Radiological Events" and "Medical Implications of Biological Terror." The course is designed to provide participants with new skills in areas such as defining the threat, writing SOPs, debriefings, dealing with post-traumatic stress disorder, setting up information centers for families and managing the media.

At the conclusion of each workshop, a drill is given in event management in which participants are given specific tasks to test what they’ve learned, including managing the incident scene and organizing the hospital, emergency department or operating room. Logistics are worked out as to who takes charge, who reports to whom, when the army is called in and how the various services are coordinated.

The value of volunteers
An entire morning is devoted to working out alternative methods of communication between the command station and medical staff should the telephone and cell phone networks fail. In this event, the communication system has to revert to basics, and volunteers would be used to run messages and carry instructions between departments. An entire lecture is devoted to how to use such volunteers effectively.

Volunteers fall into two categories: bystanders at the scene of an incident who are willing to help and can be organized to assist effectively by carrying out simple tasks, such as helping load patients into ambulances, passing equipment to ambulance crews and keeping onlookers away and volunteers in the hospital who are familiar with its procedures.

Hadassah has an official volunteer organization made up of retired men and women with medical and non-medical backgrounds who are trained to perform a large variety of tasks in the hospital, including administration and assisting doctors and nurses in the wards and the emergency department.

In times of emergency these people, who are already trained, and know their way around the hospital are used for the specific tasks they know well. They change bed linens, refresh supplies on the trolleys, answer phones, and check with the radiology department for X-rays that are ready for collection.

The writer, who has a paramedical background, served as a Hadassah volunteer for several years in the emergency room at the hospital's facility at Mount Scopus where he ran EKGs on patients and checked temperatures and blood pressures until the early hours of the morning.

Drills and partners 
Live drills directly related to biological or chemical threats are carried out once or twice a year and are timed to see how quickly they are executed and how long it takes to diagnose the substance used. Close attention is given to how personnel use protective equipment and the time taken to don protective gear.

Surprise drills are also carried out to test the alertness of emergency department staff. In one such drill, a woman soldier appeared in the emergency room with symptoms suggesting anthrax exposure. She succeeded in passing through all the procedures and reaching the X-ray department before someone realized what her symptoms revealed. Had this been a genuine case of anthrax, the emergency room staff could have been exposed.

One of Hadassah Medical Center’s partners in mass-casualty preparedness is Magen David Adom, Israel’s national emergency medical, disaster, ambulance and blood bank service. Jonathan Yagodovsky, MDA’s international director, emphasized the seriousness of their response to a mass-casualty event. When the first call is received, it isn’t yet known how many injured there are, so MDA dispatches about 40 ambulances, both advanced and medium life support, each supplying a different level of treatment and facilities. On the average there are more than 100 medical personnel at the scene, most of whom are paramedics. This number is boosted by doctors who volunteer their services when the news of a major incident gets out.

All ambulances carry a respiratory filtering system, masks, filters and tissue protection kits in the form of overalls that protect the body from chemicals.

Julie Benbenishty, coordinator of the workshops and a former ICU nurse, spoke about a new development under which MDA ambulances are equipped with digital cameras so they can photograph the situation at an incident scene. Back at the hospital, the footage can be displayed on a monitor, potentially providing clues as to what a chemical agent might be, or other useful information.

The MDA takes part in exercises all over the country with fire and police agencies, hospitals and municipalities, all of whose personnel are trained for mass-casualty scenarios as part of ongoing training programs.

Asked what his assessment was of Hadassah's state of preparedness, deputy director Shmuel Shapira said, "I am confident that my staff is fully prepared for any eventuality, but the only way to maintain the status quo is to continue carrying out drills. Protocols should be constantly reviewed and updated."