Israel Course 2005

Community Hospital Visit and Graduation Day

2005-11-17T23:33:00.000+02:00

DAY 5:

We began the last day of our comprehensive training program with a trip to the Ha’emek Medical Center in Afula.

Afula is a small city located in the Jezreel valley in northern Israel. Its origins are Biblical: Gideon of Judges (chapters 6-8) hails from Ofel, which is thought to be the ancestor of present day Afula. The city was founded on 31 March, 1925, by American immigrants. In-between, several Arab villages stood on the spot: al-Affulah was built by Saladdin, which later came to be called al-Fulah. This disappeared around the turn of the century. Now it's a municipality of more than 200,000 people. Many of those live up on the hill below which the rest of the city lies. This hill is called Givat Hamoreh, and the section of the city that sits on it is Afula Illit ('upper Afula'). Down below is the commercial section of the city, which is a perfect miniature version of the cultural diversity and unique dichotomy of ancient and modern that characterizes Israel itself.

Afula is a cross-section of Israel is to just watch the people in this traditionally lower-income city. You will, on any given day, see ultra-Orthodox Jews, SephardicJews, Ethiopian Jews, Russians, and Arabs all interacting in the same small space. Russian is in fact heard almost as commonly as Hebrew, and many stores will have signs only in Russian. Arabic and Amharic can also both be heard frequently. And, like everywhere in Israel, nearly everyone speaks some English.

According to the Orna Blondheim, the director of the Ha’emek Medical Center,the hospital was founded 80 years ago by pioneers who were draining the swamps in the Jezreel valley and were afflicted by infectious diseases such as Malaria. The hospital grew into the largest community hospital in Israel and the largest local employer (1800 staff members). It currently has 490 beds, 24 departments, 60 outpatient clinics, a School of Nursing and is serving a population of 500,000 with a staff of 250 doctors and 600 nurses.

According to the hospital statistics last year the medical staff performed 4500 deliveries, 16,000 surgeries, and managed 130,000 emergency room visits, 200,000 clinic visits and 40,000 admissions. The hospital has an academic affiliation with the Rappaport Faculty of Medicine at the Technion in Haifa and its Department of Family Medicine is affiliated with Chaim Sheba Medical Center in Ramatgan. In 2004 Ha’emek Medical Center was voted as the Outstanding Hospital in Israel.

Afula is not only surrounded by kibbutzim and moshavim, but also by several Arab villages and towns. The Israel - Arab population grew from 150,000 in 1950 to 1,200,000 in 2000 and Jews and Arabs attempt to live together peacefully. The city is also only a stone throw away from the former “Green line” and the proximity of Jenin contributed to a wave of devastating suicide attacks. Even though the construction of the separation wall has contributed to a dramatic drop in terror attacks, homicide bombers still target the city and its surroundings.

The hospital has carried a heavy burden in caring for the victims of such attacks and therefore has acquired experience in the management of trauma victims.

Ha’emek Medical Center has the ONLY trauma center in the region treating 800 terror victims since 10/2000. This would translate to the equivalent of 150,000 terror victims, if the same amount of terror attacks would have occurred in New York!

The hospital can only deal with this enormous burden of trauma victims by optimizing its emergency and disaster response system.

It has currently 175 trauma beds with a surge capacity of 350 beds. In case of a multiple casualty event (MCE) automatically mobilizes its entire medical staff to be able to receive a maximum amount of trauma victims. It is limiting its use of diagnostic facilities to speed up the diagnostic testing for the trauma victims, strictly abides to a uni-directional patient flow model (patients do not return to the ER after diagnostic testing was performed), and assigns the available medical personal according to each patients injury level. The order of activities in a MCE includes the evacuation of the ER to free available capacity, stop of routine activities, immediate assessment of the severity of the situation, rapid personnel deployment to the ER, recall of all medical staff and opening of all available treatment facilities within the hospital. Furthermore, an immediate capacity assessment of the OR, ICU, respirator, medical equipment, blood bank and specialized medical staff (i.e. anesthesiology, surgeons, ER nurses etc.) is being performed.

Afterwards, we also heard two presentations from leading geneticists, who discussed the relatively high level of genetic diseases among the local population. This is directly related to the high degree of consanguinity (46%) within the Arab population. Intermarriage within large families or tribes introduces new recessive mutations leading to the appearance of affected individuals with Thalassemia, Familial Mediterranean Fever, Cystic fibrosis, Retinitis Pigmentosa, Congenital Deafness and Nieman Pick Disease.

Following the presentations we were given a tour of several hospital departments and I was impressed by the professionalism and dedication of the medical staff.

On the last leg of our long journey we traveled along the Jerusalem - Tel Aviv highway to Latrun, the site of the Armored Corps Museum located next to a monastery, which is well-known for its wines. There are some memorial sites, as well as remains of a Crusader fortress and scenic views, along a short loop trail around the Latrun monastery.

The museum is also a memorial site of the Israeli Armored Corps and an open-air exhibition of more than 200 tanks and other armored vehicles. Some of the exhibits date back to World War I, but most of them participated in the War of Independence (1948), The Six-Day War (1967) etc. Both Israeli tanks and hostile armies' vehicles are presented.

The museum contains a memorial wall in which the names of all those brave soldiers are engraved who fell in battle for the defense of Eretz Israel. There the relatives of the fallen heroes congregate each year to honor the memory of their loved-ones. It also serves as a ceremonial site for the Israeli Army, where young soldiers receive their certificates of honor and swear their oath of loyalty to the Israeli State and its people. We were privileged to participate in such a ceremony and after a moving tour throughout the memorial site we concluded our exciting course with a similar ceremony. Boaz Tadmor led us in the Oath of the Israel Defense Forces Medical Corps and we swore to extend a helping hand to the wounded and to the sick..whether common or exalted, friend or foe.. and to be our brother’s keeper, whether in battle, on a stretcher or at the bedside.. and never to leave the wounded in the field. THIS I DO VOW. We received our certificate for the successful completion of the Emergency and Disaster Preparedness Course and were thereby qualified to volunteer in the Israeli Medical System in times of need.

After this moving ceremony we said tearful goodbyes from all of our teachers and friends and vowed to come back. B'shana haba B'yerushaleym, next year in Jerusalem.

Shalom and Goodby Israel.

Bernd Wollschlaeger,MD,FAAFP

Simulation-Based Training Provides Real Life Experience

2005-11-16T01:10:00.000+02:00

DAY 4:

We again traveled early in the morning to Zrifin to visit the outpatient clinics of the Israel Defense Forces (IDF) Medical Corps (Central Command).

We were given a brief overview of the medical services, which include 1.5 Million visits/year provided mostly by primary care physicians (only 11% specialists) comprised of drafted physicians with less then three years clinical experience.

The presenter emphasized that the physicians are being supervised by senior medical officers. The IDF also utilizes a comprehensive electronic health record system allowing for the immediate access of vital medical information of every soldier serving in the IDF.

Afterwards Dr. Zohar Rubinstein, the chief mental health officer of the home front command, gave us a comprehensive overview of the evaluation and management of Acute Stress Reaction (ASR), Acute Stress Disorder(ASD) and Post Traumatic Stress Disorder (PTSD). He emphasized a characteristic timeline consisting of a Preparation Phase, Impact Phase and Rehabilitation Phase.
Early intervention would include the education of the population about risks of mental health disorders occurring during a terror or war related event, the recognition of signs and symptoms of any such stress related reactions during the impact phase and trying to prevent the emergence of PTSD, which is often extremely difficult to manage during the Rehab Phase.

He reiterated that the dissemination of objective information during the Preparation Phase can provide a degree of “mental immunity” that appears to decrease the risk of ASR, ASD and PTSD.

The lecture was followed by small group exercises during which each participant learned to utilize a Preliminary Focused Intervention Protocol (PFIP).

In the afternoon we traveled to the nearby Chaim Sheba Medical Center (Tel Hashomer), which is one of the largest hospitals in Israel (2000 beds, 850 MD’s & 2000 RN’s, 120 clinical departments).

There we visited the “Israel Center for Medical Simulation” also known under the Hebrew acronym MSR (Merkaz Simulatia Refuit).

The MSR is a world-leader in simulation based medical education and the program devised is intended to improve patient-safety and healthcare professional’s skills through new approaches to training and clinical practice.

MSR provides hands-on experiential simulation training in a wide variety of clinical domains such as Anesthesia, Cardiology, Ob-Gyn, Trauma, Biological and Chemical Warfare and more.

The MSR was founded in 2001 by Dr. Amitai Zvi, a pediatrician and Deputy Director of Sheba Medical Center. Dr. Zvi was first exposed to simulation-based training as a combat pilot in the Israeli Air Force applying now the same methodologies in the training and continuous education of health care professionals.

During the four years of its existence the 20,000 trainees have completed a variety of courses at the MSR including simulation-based screening exams for medical school applicants and training for interns transitioning into the medical practice.

The simulators have been provided by Symbionics, the world leader in medical simulator equipment.

The benefits of medical simulation include training in a safe environment, proactive clinical exposure for the trainee, focus on cognitive learning, team work followed by an extensive debriefing session.

Afterwards, we broke out in small groups of six trainees and underwent three simulation-based training sessions including trauma management, recognition and treatment of biological and chemical warfare victims.

The realistic learning sessions provided an intense learning experience and were enthusiastically received by all participants.

A Day Of Drills And Exercises

2005-11-15T00:30:00.000+02:00

DAY 3:

Early in the morning we traveled to Zrifin to visit the Assaf Harofeh Medical Center.

Assaf Harofeh Medical Center, the third largest hospitals in Israel, is an 800 bed facility, providing comprehensive medical services to a population of almost 500,000 in Central Israel. It is located on a 60 acre campus only 15 km from Tel Aviv and Ben Gurion Airport.

The Medical Center is named after "Assaf The Physician" who was the author of the oath for Jewish Physicians written some 1,500 years ago. The Medical Center is dedicated to the spirit of this great physician. Assaf Harofeh Medical Center was once used as a military hospital serving a British Army camp before the creation of the State of Israel. Its first known existence was in 1918 when the British conquered land from the Turks during the First World War. With the declaration of the Independence of Israel, the hospital was converted into an Israeli medical facility. Since that time, the Medical Center has played a major role for the citizens of the area, from having been the National Center for victims of Polio during the 50's to being rated as one of the top medical and teaching facilities in Israel today. In the 1980’s the hospital transformed itself from old barracks into a modern and highly sophisticated Medical Center providing all the major services of a modern medical facility for a complete medical care package. It offers 24-hour emergency services, intensive care, general medical, surgical, cardiac, pediatric, neonatal, gynecological and obstetric medical services as well as ambulatory psychiatric services are available.

The hospital is an academic teaching facility and is part of the Tel Aviv University Sackler Faculty of Medicine. All the clinical wards are accredited for specialist training by the Academic Council Of The Israel Medical Association. The first and largest Academic Nursing School and the oldest School of Physiotherapy in Israel are located on the hospital grounds.

At the hospital we were greeted by its Director Dr. Benjamin Z. Davidson, MD who gave us an overview of the history and function of his hospital.

The hospital provides in- and outpatient care for almost 400,000 patients/year including 133,000 Emergency Room visits.

He proudly pointed out that Assaf Harofeh Medical Center has a state-of-the art comprehensive breast cancer center, a complete dialysis center serving 31,000 patients/year and is the only hospital in the country offering a soup kitchen program including “meals on wheels” serving the poor and needy.

He also emphasized that the medical center conducts at least three emergency and disaster preparedness drill per year including preparations for conventional and unconventional weapon scenarios and is refining its response to such potential threat scenarios after each drill.

As part of our visit the hospital organized a complete preparedness drill based on assumed bombing using cyanide an unconventional weapon agent.

We witnessed at first hand how the medical staff was managing 25 patients who arrived in ambulances at the hospital, were decontaminated outside the hospital, treated in the emergency room and then referred for admission to the various medical floors all within 45 minutes.

Afterwards we were provided the opportunity to interact with the staff, critique their performance and then tried out to wear a protective suit. The NBC Protective Suit is worn in conjunction with a respirator, gloves and overboots, and offers protection against all known chemical warfare (CW) agents. The complete suit is constructed from two layers.
The outer material is made of monacrylic fibres reinforced with polyamide fibres. It has a strong, hard-wearing outside surface. A silicone treatment is applied to make the garments shower-proof, and to permit rapid spreading of liquid chemicals, which in turn speeds up evaporation. This reduces the loading on the second layer, whose main function is to act as chemical barrier. The inner fabric is based on activated charcoal as a means of protection against toxic gases and vapors. It is s bonded to a non-woven fabric, which is flame retardant. A fluorocarbon finish is applied as an oil repellent, thus acting as a further barrier to toxic liquids. This combination of repellents represents a chemical barrier which is highly efficient, yet air permeable and thus imposes low heat stress. This liquid control system formed by a wicking layer over an oil-repellent layer permits the incorporation of less charcoal than in other systems, which in turn results in a fighter garment and smaller package size. Event though the charcoal impregnated protective inner layer of the suit allows for some air exchange the temperature within the suit rises fast. After 10 minutes I started to sweat and was told that this suit can be worn for up to 24 hours requiring frequent oral hydration with the help of a plastic straw integrated into the face shield.

In the afternoon we continued our journey and visited the Search and Rescue Team of the IDF Homefront Command. The function of the Home Front Command's Search and Rescue unit is defined as follows: a command rescue force intended for performance of distinct S&R missions in the country as well as abroad, in peacetime, in war and in emergency, anyplace and at any time as needed.

The unit was established at its current strength in 1984, combining all the specialist units that were involved with S&R until that time. The unit has participated in many special S&R operations in Israel and abroad.

Operations abroad included:

Mexico, 1985.
Armenia, December 1988, following the earthquake.
Buenos-Aires, Argentina, 1994, following a terrorist bombing.
Nairobi, Kenya, 1998, following the terrorist bombing of the US Embassy
Turkey, August 1999, following the earthquake.
Greece, September 1999, following the earthquake.
Turkey, November 1999, following the earthquake.
India, February 2001, following the earthquake.

Operations in Israel included:

Versailles halls incident in Jerusalem (23 died, > 300 injured, response time <1>
Gas explosion in Tel Aviv

The S&R unit is a rapid mobilization force and has an airborne transport and deployment capability for its men and equipment. The human element of the unit is comprised of highly trained professional reserve personnel and a regular formation based at the Hone Front Command training facility, which remains in constant readiness throughout the year.

The S&R unit operates on a work plan determined according to situation evaluations made by experts: commanders, doctors, engineers, rescue technicians and heavy equipment operators. The evaluations are based on up-to-date field reports on relevant topics such as types of structures collapsed, local conditions affecting movement capability of heavy equipment, estimated number of persons trapped under the rubble and so on.

The unit operates state-of-the art specialized equipment, among the most advanced in the world, including the TPL - a locally developed device for locating persons trapped under rubble by detecting seismic and acoustic emissions given off by the victims.

The S&R unit also uses search and rescue dogs specially trained to locate people buried under debris.

We witnessed a live exercise in the evening hours lasting 30 minutes with the goal to retrieve victims buried under the rubble of a collapsed building. It was impressive to witness the team of young soldiers (women and men <20>

Visiting The IDF Military School

2005-11-14T20:41:00.000+02:00

DAY 2:

We left the hotel early in the morning to visit the medical training facilities of the Israel Defense Forces (IDF) in Zrifin.

The military medical school is situated on the outskirts of Tel Aviv within the largest military base in the country.

There we were greeted by Colonel Erez On, MD, the Deputy Surgeon General of the State of Israel. In his speech Colonel On emphasized the importance of the course and expressed his gratitude for our willingness to volunteer our time for the welfare of the State of Israel.

The introduction was followed by a series of lectures delivered by top-ranking military officers. The Head of the IDF Trauma Medicine Branch presented the advances made in the management of casualties in conflict situations. The Head of the IDF Radiological and Nuclear Medicine Branch reviewed the principles of dealing with the effect chemical, biological, radiological and nuclear warfare modalities and the Head of the Israeli Search and Rescue Unit shared his experiences gained by the units’ world-wide deployment.

Afterwards, Colonel (reserves) Gil Shenar summarized the principles of community disaster management and risk communication.

The following represent just some of the highlights of each lecture:

The IDF’s military school is the only facility in Israel offering Advanced Trauma Life Support courses certified by the American College of Surgeons. These courses are open to all healthcare professionals in Israel and its graduates include Palestinian physicians. Each year 700 healthcare professionals undergoing the course and obtain ATLS certification.
The average time of evacuation of combat casualties is 53 minutes in high intensity conflicts and the on-site medical care is crucial to guarantee survival. It’s important to understand that most casualties die within 30 minutes of injury unless optimal trauma care is being initiated.
All penetrating injuries are considered bleeding injuries and treated as such.
The military surgeons operate according to the SCOOTER principle: scoop the patient, treat and run (quick evacuation and referral).
The IDF’s CBRN Branch (Chemical, Biological, Radiological and Nuclear) provides advice and guidance for the entire population in the State of Israel.
The press and other media outlets should be considered as first responders. Therefore it is crucial to provide accurate, honest, truthful and updated information to the media.
The information delivery to the media needs to be practiced and tested as part of the community disaster preparedness. Everybody talking to the media should be trained and receive detailed instructions.
Schools should be involved in the community preparedness efforts. Informed children are less prone to succumb to fear and can guide their parents, who might not have a full command of the language (new immigrants)
A panic stricken public represents an unorganized entity, which can be organized by using optimal information delivery and distribution.
Natural disasters claimed 3.5 million lives over the last few years and community preparedness should also include readiness measures for nature-made disasters.
The Israeli Search and Rescue Unit was established in 1982 and includes 250 military personnel (physicians, paramedics, first aid medics, technicians etc.).
The unit operates as ONE military unit, but can also function as independent individual units (maximum 9 units).
The Search and rescue Unit can be on-site of a disaster within 3-12 hours and has been deployed world-wide.
One of its goals is to reduce the chaos phase after a disaster, establish order, rescue and treat as many victims as possible.
Intraosseous infusions via bone injections is the preferred access for fluid delivery.
The medical personnel includes physicians, paramedics and first-aid medics trained to deal with complicated traumatic injuries and to treat crush injuries on-site.

After the lectures we visited the sophisticated medical simulator, which provide optimal training conditions for health care professionals. Multiple casualty scenarios can be simulated including sound and light effects providing battlefield like conditions. The performance of each participant is being videotaped from different angles, critiqued and reviewed during a debriefing.

This presentation was followed by a live exercise performed by a group of medics guided and supervised by a combat surgeon.

APF's November Course in full swing

2005-11-13T23:16:00.000+02:00

November 13, 2005:
After a long flight with stopover in Frankfurt I arrived in Tel Aviv on November 11th just in time before Shabbat.
After enjoying a wonderful Shabbat dinner at a friend’s house I relaxed on Saturday to get over my jet lag.

In the afternoon I walked around in Tel Aviv, my city I haven’t visited for 14 years. A lot has changed and the hospital I trained at (Ichilov) is now a super-modern medical center.

I crossed Kikar HaMedina paying homage to the great Israeli statesman Yitzhak Rabin who was murdered at that site by a radical Jew 10 years ago. Incidentally, the preparations for a large memorial celebration were in full swing where latter that day former President Clinton gave a moving speech to honor his friends Yitzhak’s memory. “Shalom Chaver – Good-by my friend” said a tearful President Clinton and it came from his heart.

I returned to the hotel to get ready for the introduction of the emergency and disaster preparedness course.

This course is a joint venture of the American Physicians Fellowship for Medicine in Israel, the Ministry of Health of the State of Israel and the Israel Defense Forces.

This five day intensive medical emergency and disaster preparedness course is focused on the integration of volunteer medical personnel from abroad in the Israeli health system and its main objectives are:

Acquainting the participants with the Israeli medical emergency preparedness, contingency plans and deployment of the health organizations in emergencies and disasters.
Training potential volunteers in emergency and disaster medical treatment and management, in order to promote their ability to operate in mass casualty events and other emergencies.
Strengthening the relationships between the Israeli medical organizations and all potential volunteers, to enable effective function during emergencies.

Upon completion of the course, the participants will be capable to rapidly integrate and function in the Israeli medical system in emergencies. Furthermore, the knowledge and capabilities which will be gained via the participation in the course, will assist the physicians to promote the emergency preparedness of their own institutions in the US.

This year over 50 participants and their spouses traveled from the US to Israel to attend the program. The group is comprised of physicians , nurses and EMS personnel. We are being guided by Dr. Boaz Tadmor, the former head of the Israeli Homefront Command, a world-renowned expert in emergency and disaster preparedness. On Sunday, the first day of our course program, we visited the Tel Aviv center of the Magen David Adom (MDA).

The MDA in Israel is a first-aid society recognized by the State of Israel as its only national first-aid society, which operates according to the principles of the International Red Cross and the Red crescent Societies. Unfortunately, the MDA has been denied full membership in the International Red Cross, but it appears that this conflict will be resolved in the near future.

The MDA’s objectives are as follows:

To carry out the functions of a national society, to be for this purpose an auxiliary service of the Medical Service of the Israeli Defense Forces in time of war and to prepare for this in time of peace.
To maintain general first aid-services for the benefit of the citizens of the State of Israel.
To maintain a storage service of blood, plasma and their by-products for the benefit of the citizens of the State of Israel.

Then MDA provides:

Training in first-aid and pre-hospital emergency medicine;
Encourages the training of volunteers in first, basic and advanced life support;
Transport of patients, women in labor, and evacuation of those wounded and killed in road accidents;
Transportation and transfer of doctors, nurses and medical auxiliary forces.

Several experts from the MDA, the Ministry and Health and the Israel Defense Forces presented different aspect of the emergency and disaster preparedness measures in place in Israel and shared their experience in disaster management with us.

The following represent just some of the vast array of information presented during that day:

Israel has 27 general hospitals with 14,000 beds and a surge capacity of almost 20,000 beds
All hospitals are operating under the auspices or control of the Ministry of Health
All hospitals share information about their bed capacity, availability and utilization of diagnostic modalities (for example CT and MRI) through a central database to allow for the optimal transfer and referral of critically injured patients.
Israel has 20,000 active physicians (3.7 MDs per 1000 citizens), 280 graduates each year from 4 of its medical schools and 2/3 of all practicing doctors under 65 were born outside Israel.
During the last wave of terrorism from 200-2004 (also called “Intifada”) approximately 1000 Israelis (Jews and Arabs) were killed and 7000 were injured in 1653 terror acts.
The terror weapons of choice are explosives concealed in belts worn by homicide bombers, which are also spiked with nails and other metal objects intended to inflict maximal damage on innocent victims.
The most lethal injuries are inflicted by explosions in enclosed spaces (i.e. buses, bars, restaurants) with a 20% mortality rate.
Israel has a centralized trauma registry with 1661 entries of those victims, who were hospitalized & admitted.
Each patient record encompasses 200 data filed and provides an extensive database for analysis and research purposes.
The average age of all victims is 15-29 years.
Injuries include a combination of burn, blast, blunt and penetrating injuries and require customized and individualized care (example: burn injuries requires increased fluid intake and blast injuries –lung- require fluid restriction and the combined injury demands skillful treatment and invasive monitoring)
In bus explosions dominant injuries to head & neck and in open air explosions dominant injuries to thorax.
The average ambulance response time to the site of a terror act is 6 minutes and the first injured can be evacuated in 7 minutes after the blast!
Israel has a preparedness plan for a so-called mega terror event, which can overwhelm regional resources requiring recruitment of national resources.
In a mass casualty event a command structure (role of incident commander) allows for the reduction of the so-called initial chaos phase and seamless integration with police and military commanders.