Day one
The first day of the Emergency Medical Seminar started after lunch, Sunday being the first day of the Israeli working week. Vicki Angel, Director of Magen David Adom (MDA) Resource Development, hosted the introductions, stating that the goals of the seminar was ‘to provide an understanding of the Israeli Emergency Medical System (EMS); to provide information about disaster preparedness and operations around the world; and to establish a relationship between MDA and participants from various countries.’
There were 11 participants representing the USA, Italy, Sweden, Brazil and the UK.
The first speaker was Yoni Yagodovsky, Director of MDA's International and Fundraising department, who presented a talk entitled: ‘Introduction to MDA: Israel's National EMS and Blood Services’. This included a brief history of MDA, its legal status within Israel and internationally as part of the Red Cross, and its duties and goals. Yagodovsky also spoke of the financial, governmental and medical controls of MDA; the importance of volunteers within the system; income (30% from donations, 70% from services); MDA as an auxiliary arm of the Israeli Defence Force (IDF); and the collection, processing and distribution of blood and umbilical cord blood.
Interesting points that Yagodovsky mentioned included the fact that staff unable to continue working on ambulances are offered either office positions or jobs in the blood bank; community first responders (CFRs), although still volunteers, receive continuing training to paramedic level; and that all emergency medical dispatchers have worked on the road before being promoted to the Emergency Operations Centre (EOC).
He also spoke of the re-routing of unanswered emergency calls within 7 seconds to other EOCs; the emergency treatment of patients from neighbouring states; as well as other Red Cross activities such as reuniting families and international humanitarian activities.
In the evening, Dr Bruria Wiesel, a senior consultant to the Ministry of Health, presented: ‘Preparedness of the Israel Health Care System for Emergencies’. Wiesel spoke of the government's planning and preparedness for CBRN, conflict and natural emergencies. Factors she included were the recognition and diagnosis of psychological issues after mass casualty incidents (MCI); diversion of patients to specialist units; the congestion of emergency departments; and surge capacity management (a mandatory surge capacity of 20% of bed capacity).
Interesting points that Wiesel mentioned were the surprise drills meant to test the complete system, including the EOCs, EMS’, police, fire services, hospitals, as well as governmental response. She also showed us the ADAM system, which allows the public to locate and identify family members via a web portal.
Next to speak was Dr Eli Jaffe, Director of MDA's Training, Volunteers, International, PR and Fundraising division, who spoke of the volunteer system within MDA. They have approximately 14 400 volunteers, of which 7 400 are pre-military service, and approximately 40% are at medical schools. After a year of volunteering, participants get pagers enabling them to work as CFRs, and the eight closest are dispatched to scenes when required. Along with their responder vest, medical kit, oxygen, radio and AED, CFRs living near borders must also carry their passports, as they may be called to assist in Jordan or the Sinai. He also told us that volunteers crew ambulances alongside regular staff, and are even invited to take part in international relief operations. Alongside these programmes is the Yochai Porot programme, which hosts approximately 500 volunteers aged 18–30 years from all over the world.
Finally, after supper we had the chance to listen to Chaim Rafolowski, the MDA Disaster Management and EU Projects coordinator, whose presentation was on ‘Mass Casualty Incidents and Disasters—a continuum of different issues’. He spoke mostly of his experiences in Haiti and the Philippines. The Israeli contingent in Haiti set up a field hospital to provide surgery, prostheses, and psychological support, and a small team remained to provide training in MCI management. He spoke of the importance of providing non-food items, such as tarpaulins and ropes; how satellite telephones were blocked by the press; and how the lack of refrigeration meant using older means of infection control, such as putting honey on wounds.
Day two
The second day started at 08:30am, with Guy Caspi, MCI Chief Instructor and Director of HAZMAT Exercises, Operations division, talking about ‘Emergency and Disaster Preparedness: EMS Response to suicide terrorism’. He expounded Bruria's description of all-inclusive training and drills, and they routinely run scenarios for MCIs, various CBRN scenarios, natural disasters, and war. Every staff member in MDA carries a small card of simple, standing protocols in the event of MCIs, in case the communication system was severely affected.
Caspi also spoke of terror attacks, outlining how suicide bombers were virtually undetectable and unstoppable (‘walking smart bombs’). He provided information of the 2004 bus bomb in Jerusalem, where there were 10 deaths and 77 casualties, with an extra 19 who self-evacuated and made their way to hospital. He said that the time frame from when the first call came in to the EOC to when the last patient was transported was 26 minutes, despite the narrow, blocked roads. The bus was also cleared that day, in order to limit the visual impact and propaganda value.
Caspi went on to mention the importance of using large numbers of bystanders who are anxious to help; how bone and tissue become penetrating objects; and how paramedic crews have bomb-scene procedures to provide immediate evacuation despite the potential for secondary devices.
The next to speak was Erez Geller, Deputy Director and Supervisor, MDA Carmel Region. He presented: ‘Emergency and Disaster Preparedness: 2nd Lebanon War [2006]’.
Geller told us some interesting facts: that during war teenage volunteers are not used; blood donations continued despite rockets falling outside (33 000 donations during 33 days of war); and how they learned not to dispatch vehicles immediately to every suspected rocket falling, because their crews were spread too thinly; and how they learned to send vehicles in a ‘brick’ of an MICU with two basic vehicles.
Geller spoke of how same-day group debriefings with a psychologist reduced stress-levels amongst his staff; how due to people panicking during rocket attacks, ambulance crews had a protocol to pull over and wait for two minutes, to avoid people driving into them. He also mentioned the importance of officers needing to be on a first name basis with officers from other agencies before MCIs, and how inter-service training promoted that.
After lunch we went to the MDA Training Centre for Paramedics and Medical Teams. There we met Udi Gelbshtein, Deputy Director of MDA's Training Centre, who presented: ‘Training of Medical teams and the role of MDA Paramedics in Mass Casualty Events’.
Gelbshtein spoke of paramedic training: the first course having started in 1979, and to date 2 200 paramedics have graduated from 84 courses. He told us that military paramedics did the year-long MDA course (based on the United States Department of Transport paramedic programme), with the inclusion of tactical medicine, which gave them a direct career path after their three years’ service. For the volunteer sector there is a three-year part-time paramedic course. Nurses also could choose to do an accelerated paramedic course as the final year of their nursing degrees. There is also a combined nursing and paramedic degree spanning four years at the Hebrew University in Jerusalem; and a BSc Emergency Medical Technology at Ben Gurion University in Be'er Sheva.
Gelbshtein stated that most doctors had been taken off the road, with a greater range, skill and authority given to paramedics. A few interesting points he made included: all paramedics have to pass the medical maths module with 100%, perform surgical airways, and have to learn to do all invasive procedures in HazMat suits.
We then went to the MDA National Medical Dispatching Centre, then a visit to the garages to see MDA rescue and emergency vehicles, the MDA ‘Wish’ ambulance, which takes terminal patients on excursions, motor trikes and a segway, normal and bullet-proof MICUs, and a Command and Control Vehicle with an extendable mast and cameras that are controlled remotely by the EOC.
Day three
Day three started with Prof Yehuda Skornick, a former MDA President and current Director of the International MDA Medical Forum, speaking about MDA activities around the world. He told us about the very close relationships between MDA, the Red Cross, and the Red Crescent, as well as the military field hospital in the Golan Heights that was treating Syrian refugees. He spoke of MDA's activities in Georgia, Sri Lanka, Azerbaijan, China, Turkey, Indonesia, Maldives, Jordan, Myanmar, Panama, Haiti, South Sudan and currently, Philippines.
We then went on a trip to Assaf HaRofeh Medical Centre, where Dr Gadi Sadovsky, Director of Emergency Preparedness, spoke to us about: ‘Preparedness of hospitals for conventional and non-conventional Mass Casualty Events’. Assaf HaRofeh is an 832-bed teaching hospital for three medical schools, but has to cope with an extra 160 casualties above the 832-beds in times of MCIs. This is achieved by having extra stores of beds, and mass casualty and CBRN kits; changing the focus from non-trauma to trauma beds in wards; by changing shifts from 8 hours to 12 hours; and the ability to call extra staff from other wards, from home, or the military when required. Interestingly, when required, an emergency nursery can be opened in the hospital, run by girls from the army, to alleviate concerns of staff about their children.
Sadovsky told us that the multi-service drills are evaluated by the Ministry of Health, a nearby hospital, as well as by self-evaluation, and are intended to test organisation, logistics, headquarters response, operating rooms (22 in total, two dedicated to emergencies, seven kept free constantly for MCIs), information centre and security services.
Afterwards, on the way to lunch, Sadovsky took us on a tour of the hospital, which included pre-installed decontamination showers in the parking lot, allowing for the simultaneous decontamination of 12 walking and 24 stretcher patients.
After lunch, we visited Holon Ambulance Station to see what a small station looks like, en route to the Blood Services Centre of MDA. Here we were taken on a tour which included the collection, testing labs, and despatch areas, as well as the areas for storage of umbilical cord blood and rare blood-type samples. We were told of how Israeli citizens came out in droves to donate blood at times of war, to the extent that many were told to return in a fortnight. The highlight of this visit was being able to enter the British-built MDA mobile EOC parked outside of the blood centre.
Day four
Day four saw us on the way to the IDF Home Front Command Medical Corps HQ. Col Avi Abargeal, Chief Medical Officer of the Home Front Command, explained the reasons for Israel's concerns regarding earthquakes: they sit astride three tectonic plates. He also told us of the ‘Pillar of Defence’ onslaught last year, where 1 500 missiles were fired at Israel, causing 268 casualties and six deaths. He also mentioned that Syria had 1 000 tons of sarin: enough to destroy all of mankind.
Avi told us that the Home Front consists of 5% regular staff, 95% reserve forces, and it can take up to 72 hours to call maximal staff up. In times of crisis, the army needs 400 ambulances, which MDA keeps in storage. Understanding that at times of war MDA staff are called-up, they can then be re-deployed to work on ambulances again as serving soldiers.
We then went to Jerusalem's Bloomberg MDA station to take part in a mass casualty drill. We were briefed by a paramedic that we would be going in crews of two, with a driver, to a scene of a mass shooting, and to expect the scene was safe. The first crew on scene would announce themselves as scene commander, and begin the triage. The remaining crews would treat and transport approximately 15 patients. The ‘patients’ were all MDA youth volunteers, with very well-done moulage, and they acted their parts well. The only criticisms were aimed at the general lack of planning of the exercise, and interference during the exercise by instructors. Interestingly, we were told that at an MCI there is no vehicle ownership, and any crew can jump into a full ambulance, and transport patients to hospital.
After lunch and a chat to the volunteers, some of whom were still in make-up, we were taken on a tour of the old city of Jerusalem. There we were taken to an MDA store by one of the religious volunteer paramedics, where we were shown one of the narrow vehicles used by the MDA to transport patients through the narrow streets of Jerusalem.
Day five
The final day began with an early start: 06:30am for eight-hour ambulance shifts. This went relatively well for a few of us, and the paramedic crews we were placed with were welcoming and keen to share with us, for others on the seminar unfortunately they experienced crews who were less than happy to have them on board. A highlight for me was seeing how Israeli paramedics certify death on scene, providing death certificates for the family to start organising the funeral almost immediately.
In the evening, we heard Prof Pinchas Halpern, Director of the Department of Emergency Medicine, Tel Aviv Medical Centre, present: ‘Emergency Medicine: the Israeli Example’. Halpern spoke of staffing in the emergency department (ED), with extra staff being called down to ensure at least one doctor and one nurse at each bedside; registration clerks following patients into the ED to get their details, placing radiofrequency ID tags on them; and management being led by the ED consultant and chief surgeon. Security consists of a bomb squad outside the ED checking for devices; 360-degree fencing around the hospital; gate control, and all ambulances are checked by security. During MCIs staff are forbidden to call in after being bleeped, as this has been found to tie-up telephone lines, but they are encouraged to follow social media to communicate with colleagues.
Comments
This was a well-thought-out seminar, and kept us busy for five very packed days. It was also very well-organised to the extent that timings were kept almost spot-on. The food provided was more than adequate, and there was never a lack of refreshments, and we found the MDA staff very approachable and helpful. The subject matter, although occasionally repeated by the fairly eminent speakers, was presented from their own points of view, so was constantly providing thought-provoking material. The cost of the seminar was well-subsidised, and included accommodation and half-board.
To sum up in Vicki Angel's closing words: ‘I am doing this because saving lives is the ultimate goal.’