Members of the medical and allied health professions hope never to be tested under conditions wherein the humanitarian mission of rendering health care is pitted against the concern for personal safety. However, throughout history, hospitals around the world have found themselves in such a position. One of the first such reports in the medical literature describes the activity of the Royal London Ophthalmic Hospital (Moorfields) during the “Blitz” of London in 1940 and 1941.1 To deal with treating casualties under attack, the hospital reserved beds for casualties, moved elective activity out of the city, moved to a basement location, and went through a nighttime routine, with patients and staff sleeping in underground shelters and expecting casualties from frequent night air raids. The hospital was directly hit twice during the war but immediately resumed its function. The report in the British Journal of Ophthalmology presented a fascinating story of the bravery and devotion to patients on the part of the hospital’s medical and nonmedical staff. Another hospital that functioned under extreme difficulties and physical threat was the Jewish Hospital in Budapest, during the Nazi occupation of Hungary in 1944 and 1945 and during the later combat between the German and Russian troops.2 The medical teams, working under very difficult conditions, admitted patients and a large number of injured or wounded war casualties. In spite of the almost impossible general conditions under which the medical staff functioned and the extreme lack of supplies, they were committed to their mission to provide medical care. More recently, Hebrang and colleagues3 reported from Croatia about the management of injuries during the Croatian War of Independence from 1990 to 1995 and about providing civilian–military medical service during times of combat. Their article described the high level of success of the medical staff, despite a severe lack of equipment. Other examples of working under threat and uncertainty include the efforts of medical personnel to render care during the SARS epidemic of 20024 or after the devastation inflicted along the U.S. Gulf Coast by Hurricane Katrina in 2005.5 The intensity of the clinical activity at a medical institution operating under conditions of personal risk to staff often has a way of sharply focusing the concentration and revealing collective strengths based on the highest ideals of the health care professions.
For five weeks during the summer of 2006, the staff of the Rambam Health Care Campus (RHCC) in Haifa, Israel, was put to a test similar to those described above, as an institution in the middle of a large-scale conflict occurring in northern Israel and southern Lebanon. The RHCC, the largest academic medical center in northern Israel, together with other hospitals in northern Israel, was called on to render both routine and emergency clinical care and even to continue its teaching and research activity while under near-daily rocket bombardment. This unusual situation for a major academic medical center presented challenges (some unanticipated) at the institutional and individual levels and necessitated immediate improvisations and solutions that are not part of the routine hospital repertoire.
The RHCC’s Strategic Position in Northern Israel and Its Preparedness for Mass-Casualty and Emergency Situations
The RHCC is a nearly 1,000-bed academic medical center complex, the largest in northern Israel. Within the campus, the Rambam Medical Center (RMC), the Rappaport Faculty of Medicine of the Technion–Israel Institute of Technology, and the Rappaport Institute for Medical Research are in close proximity. The Rambam serves as the sole tertiary-care medical facility in northern Israel, includes all the major medical and surgical disciplines, and is the only Level I trauma center in northern Israel. The hospital, which was founded by the British government in 1938 for regional strategic reasons, grew to its current size after the state of Israel was established in 1948. In 1969, the medical leadership of the hospital founded a Faculty of Medicine on the Rambam campus, which later became affiliated with the Technion–Israel Institute of Technology. The Faculty of Medicine and the Rappaport Research Institute, in conjunction with other teaching hospitals in the vicinity, educate more than 120 medical students per year and serve as a large, allied health education provider for all of the paramedical professions. Basic and applied research laboratories are an integral component of the campus. A summary of the scope and activities of the Rambam hospital staff in 2005 is provided in List 1. As the table shows, the RMC has a very busy emergency department with a high annual admission rate. A large surgical load and an active ambulatory service lead to robust activity overall. Beyond the operational aspects of medical care, the large number of employees in all sectors is a major factor in emergency and riskful situations. The RMC is a Level I trauma center for all of northern Israel, with close to 4,000 trauma patients treated yearly. A trauma registry and an International School for Trauma have developed into an internationally recognized educational resource for Rambam. The center routinely conducts organizational and therapeutic protocols and is part of the National Israeli Trauma Registry.
The Rambam has been an active part of almost all of the many regional conflicts during the past 70 years. It has been part of the national preparedness program for more than 25 years and is continuously preparing and practicing for possible emergency scenarios. Emergency drills are supervised by the Ministry of Health through its Division for Emergency Conditions, Department of Hospital Preparedness for National Emergencies, which provides a national perspective and guidelines. The Rambam’s preparedness planning has focused on the ability to deal with mass casualties both in times of peace and times of war and on meeting the challenges of possible conventional and nonconventional scenarios. However, the possibility that the center could be under continuous fire for a period of weeks was not taken into account appropriately in the preparedness planning. The national preparedness program also involves collaboration with the various bodies that deal with emergencies, such as the Israel Defense Forces and the evacuation and transportation system of Magen David Adom (Israel’s national emergency medical, disaster, ambulance, and blood bank service; since 2006 a member of the International Federation of Red Cross and Red Crescent Societies).
The Challenge of Medical Care Under Fire: Second Lebanon War, Summer of 2006
Soon after the conflict’s beginning on July 12, 2006, the RMC was notified of an emergency condition and took the necessary measures to prepare its emergency and surgical teams. Two days later, the first rocket that was fired from Lebanon toward Haifa hit the side of Mount Carmel, only 1,000 meters away from the hospital. No injuries were associated with this initial event. On the Sunday (a normal, busy workday in Israel) three days after that rocket fire, a major rocket attack on the train depot in Haifa resulted in dozens of injured civilians, who were rushed to the hospitals in Haifa. The RMC, along with other hospitals in northern Israel, found itself at the center of combat. Subsequently, multiple rocket attacks on the civilian population of northern Israel became a daily reality. This was a new experience to Haifa and to the RMC. From the very beginning, the RMC was faced with the following challenges:
* Provision of emergency treatment to the civilian population
* Treatment of wounded soldiers directly evacuated to the hospital from the combat area at the Israel–Lebanon border
* Referral from other hospitals of casualties who required treatment such as neurosurgery and treatment of maxillofacial, head and neck, orthopedic, and other complex injuries that was beyond the capacity of those hospitals
* Continuation of routine inpatient services and ambulatory services to the general population
* Securing the safety of the hospital for patients, their families, visitors, and employees
* Logistics of staff employment in a medical center under attack, including transportation to and from the hospital, temporary housing of some staff, establishing a secure underground location where the children of workers could find shelter, and so on
Considerations for the RMC while under continuous rocket attack
On the first day of the attack on Haifa, it became clear that the strategic threat to the hospital was real and that the hospital administration had to take measures to be prepared for a different set of challenges than were encountered during previous hostilities, when the hospital itself was secure.
The preparedness teams swang into action, and all of the established protocols for a possible emergency setup were activated. Specifically, the following actions were taken:
1. Leadership and management: An on-duty hospital director was kept on campus 24 hours a day throughout the war. Emergency forums were conducted at least once a day with the associate directors, trauma center leaders, nursing supervisors, human resources managers, and logistics and security directors.
2. Emergency staff availability: The surgical, emergency, and trauma teams were instructed to remain on campus or within a 15-minute travel time from the hospital.
3. Safety: High-risk regions within the hospital were fortified, which included shielding windows, providing concrete shields to other vulnerable locations, and other activities. These tasks that had not been part of the previous hospital preparedness program were initiated early during the war and took at least two weeks to complete. An area that could be converted into a large shelter was identified in the basement of the hospital, and an emergency air-conditioning system, provisional toilets, and communication ports were installed, to allow patients to occupy the space.
4. Preparing for psychological (anxiety) casualties: The decisions regarding the locations and logistics of dealing with anxiety casualties were taken by the leadership teams and were based on the preparedness protocol for the RMC. The general dining room was turned into an acute-anxiety-casualties center, staffed by personnel from the psychiatry and social work departments. Meals were distributed from a centralized center.
5. Hospital reorganization for safety: A reorganization that consisted of shifting departments at high risk for direct rocket hits to safer locations was not part of the previous preparedness protocol, because the possibility that the RMC would be under an attack had not been taken into account. Evaluation of the origin and direction of rocket attacks made it clear that we had to evacuate the medical and surgical departments that faced north (i.e., toward Lebanon) and were located on the upper floors, so as to minimize casualties from possible direct hits to the building. Two other hospitals in northern Israel were hit directly by rockets, in the location of departments that had been evacuated early during the war. The underground shelter that was prepared at the RMC during the first week was occupied after a massive rocket attack on the city of Haifa on August 6.
6. Communications with and support of the staff: During the first week of the war, an emergency order was issued, stating that civilians in northern Israel should stay in shelters and in fortified security rooms. Hospitals were declared “vital services,” and workers were instructed to comply with orders given by the hospital management. In general, it was required that all hospital workers come to work on a regular basis and wait for instructions regarding shift schedules, transportation, and the availability of child care at the RHCC. Individual needs were dealt with by the administrative staff under guidance from RMC directors.
7. Volunteers: Offers of help for the Rambam came from numerous volunteer groups from other hospitals in Israel, from the general population, and from friends abroad. The needs were assessed by the hospital’s human resources department, and actions to handle the many volunteers were implemented. Only those volunteers who could fill specific, identifiable needs were accepted, so as to avoid undue exposure of volunteers to potential injury; all volunteer activities were guided and supervised by the appropriate professional directors. The volunteers included physicians, teachers, and nonprofessionals who offered assistance on various logistical, medical nursing, and patient assistance needs.
8. Medical students: After the first days of the war, the teaching programs for students were reduced to a minimum. Medical students continued to participate in hospital activities and provided assistance on an individual basis. Toward the second half of the war, the dean of the Faculty of Medicine decided that attendance at and participation in the medical hospital’s activities were integral parts of the educational experience, specifically as they related to inculcation of the medical imperative to preserve health and save lives, even at personal risk. The faculty did not make participation by the students mandatory, however, and, in view of that, only a few students were present.
9. Employee management: Management of the large body of employees proceeded according to the following principles:
* Maintain the same organizational structures, even in departments where only a few patients remained.
* Encourage the continuation of routine work, even for health care employees who are not within the structured trauma operations.
* Allow previously arranged vacation time on a selective basis to avoid jeopardizing health care delivery.
* Establish a (fortified) day care center for the children of employees, which would enable those employees to continue to come to work and to remove their children from threatening conditions at home.
* Allow those in need to have access to psychological support.
* Maintain the routine of frequent visits by the hospital directors and administrative professionals to the individual departments.
* Maintain direct communications between the hospital’s executive leadership and the employees via the use of a public address system, planned meetings, and the use of an institution-wide e-mail system.
* Maintain routine and frequent meetings between the hospital directors and the emergency teams to discuss their performance.
Trauma management and clinical care
Type and distribution of casualties.
Throughout the war, the RMC functioned under continuous threat of rockets and treated civilian and military casualties, as well as medical patients. The distribution of injuries due to hostile activities, as reported by Krausz and colleagues,6 was as follows:
* Number of casualties: 849
* Number of deceased: 5
* Number of admissions: 281
* Soldiers: 213
* Civilians: 66
* Foreign workers and United Nations peacekeepers: 2
* Number of transfers: 25
Of the 281 casualties admitted to the hospital, most were soldiers; most of the rest were civilians. One was a foreign worker, and one was a United Nations peacekeeper. Many of the casualties who arrived at the hospital had acute anxiety responses. This pattern was often seen after attacks on densely populated civilian targets. Most of the patients who presented with acute anxiety were discharged without hospitalization. The 25 patients transferred from other hospitals typically were patients with more complex or severe injuries.
The staff and volunteers maintained the civilian functions of the hospital and also continued non-war-related emergency services (i.e., treatment of conditions such as acute myocardial infarction, stroke, and acute appendicitis), elective surgery, and inpatient and outpatient services for all those in need. At the same time, the administration took measures to maximize the safety of the patients and the staff under the continuing missile attacks (Table 1). The table shows that Emergency Department visits were reduced by 40% and that ambulatory visits continued at half-capacity in spite of the war situation. Elective surgery and deliveries were also reduced, but they continued throughout the war. This moderate reduction in hospital operations resulted from closure of departments for safety considerations and reductions in elective and nonelective activities. Although some of the population of northern Israel was shifted to the center of the country, most of the sick and the old remained in Haifa and its suburbs (primary care catchments area), and they were critically dependent on the medical services that were fully available at the RMC. In fact, dependence on medical services at the major hospital was much larger than normal, because many community medical facilities were at least partially unavailable.
Admissions to the hospital related to rocket fire and combat injuries were erratic (Figure 1). The peaks of such admissions during the first half of the war were primarily due to civilian injuries that resulted from the landing of explosive projectiles in densely population portions of the city and were characterized by a high proportion of acute anxiety responses. For example, the “Train Garage” event occurred at the beginning of the war; eight people died, and dozens were injured by a rocket that fell into a large train garage. The “Zim Square” event occurred when a rocket landed in a major downtown center in Haifa. The large peak in the second part of the war resulted from a combination of missile explosions in northern Israel in the center of a large aggregation of reserve military personnel and, later in the same day, a rocket explosion in a densely populated neighborhood in downtown Haifa; these events are called the Kfar Giladi and Wadi Nisnas events. Heavy fighting in Lebanon caused the increase in injuries during the last days of the war that is shown in Figure 1.
To maintain its ability to admit more injured persons and to care for them in the most efficient way, the RMC regularly transferred patients to other hospitals for continuation of their medical or rehabilitation therapy. This approach to freeing the emergency and surgical teams for new patients by transferring patients to other centers after initial treatment and stabilization was unique to this war. Transferred patients included those with light injuries, who could be easily transported to facilities closer to their homes and families; those who required longer-term management that could best be provided near their residence; and those who were ready for rehabilitation. As shown in Figure 2, transfers to other hospitals occurred continuously throughout the war and increased in the second part of the war, when more severely injured soldiers and civilians were brought to the RMC.
Among admitted patients, the distribution of injuries according to severity is shown in Table 2. Most of the injuries were mild, but substantial numbers of moderate and severe injuries were observed. Seventeen patients incurred very severe injuries. These injuries typically resulted in the use of extensive resources, intensive efforts, and long periods of hospitalization. As detailed by Krausz and colleagues,6 the injuries included 211 penetrating wounds, 73 blunt injuries, and 18 burn injuries. Some patients had more than one type of injury.
The major diagnostic and therapeutic procedures that were performed in the Emergency Department itself were 104 focused abdominal sonography for trauma (FAST) procedures for quick screening of intraabdominal bleeding, 46 tracheal intubations, 17 large-bore intravenous line insertions, and 1 emergency thoracotomy.
Injuries were distributed anatomically as follows: lower limbs, 128; upper limbs, 118; face, 65; head, 53; thorax, 52; abdomen and pelvis, 35; and burns, 25. That limb injuries were the most frequent and that face and head injuries were the next most frequent have to do with the fact that those areas are the most exposed and least protected portions of the body; the soldiers typically wore protective vests, which protected their torsos, and helmets, but the helmets only partially protected their heads and left their faces and eyes exposed.
The distribution by discipline of surgical procedures for trauma injuries is shown in Figure 3. Orthopedic surgeons were heavily involved, which is consistent with the distribution of injuries presented above, while plastic surgery, general surgery, neurosurgery, vascular surgery, and maxillofacial surgery were the next most involved. A multidisciplinary approach involved close coordination between the multiple teams that cared for these patients.
The use of imaging in the Emergency Department was extensive and is summarized by Beck-Razi and colleagues.7 FAST and X-rays were widely used. Three-dimensional multislice computed tomography (CT) and angiographic CT have become major tools of diagnosis, as shown in Figure 4. Among a total of 166 angiographic CT studies, most were chest and carotid studies or peripheral angiographic studies. The CT was established as a powerful tool in the diagnosis and guidance of therapy. The surgeons at the RMC depended on the information obtained via CT studies for a more accurate diagnosis, even at the expense of some delay to surgery. FAST, which is a quick and robust emergency department tool, was found to be 75% sensitive and 98% specific in identifying abdominal bleeding, but it also had an accuracy rate of 93% and a very high negative predictive value of 94%.7
Overall trauma service performance.
The hospital was able to fully comply with the imperatives of (1) providing the necessary trauma service for all of northern Israel as both a primary care and tertiary care health center, (2) continuing its role as the major medical center in northern Israel for all medical problems, and (3) complying with the need to secure the lives of its patients and employees. Instructions and regulations were revised daily to implement conclusions derived from the events of the previous day.6 In addition to the modern imaging technologies discussed above, new surgical methods were used, such as the repair of tears in the diaphragm through laparoscopy and the exclusion of intraperitoneal bleeding via the diagnostic technique of laparoscopic peritoneal lavage. During this time of hostilities, the injuries due to the firing of rockets armed with multiple pellets and shrapnel were characterized by many entry wounds, which meant that it was difficult to determine the internal pathological importance of each entry wound site. Only multiple CT scans and the use of angiographic CT helped the surgeons determine the extent of the injuries and the potential functional organ impairment.
Medical recommendations for emergency trauma care.
Some reports of this professional experience and the recommendations of those who worked at the RMC through the war with respect to transfusion,8 venous injury,9 and special bone and tissue reconstruction techniques10,11 have been published recently. Krausz and colleagues6 made some suggestions relating to the use of prophylactic antibiotic therapy, the performance of emergency tracheotomy, and the administration of anesthesia in the emergency room. The surgical debridement of all acute injuries, rather than treatment with antiseptics and prophylaxis alone, should be reconsidered. Others have suggested that wounds be left open for a few days and that surgical intervention take place only in the case of organ dysfunction or infection.
In the case of complex injuries that require specialists, such as urethral involvement, emergency thoracotomy, and vascular injuries, the general surgeon should initiate an intervention before the specific specialist arrives. New guidelines are required with respect to the indications for the field use of limb tourniquets, particularly for injuries of the upper extremities. In complex injuries such as limb fractures or vascular injuries, the use of a temporary vascular bypass before fixation of the bone injuries should be considered, particularly if the ischemic time is already prolonged. In head and maxillofacial injuries, maximum sparing of viable tissue for future reconstruction is important.
The financial component.
The government hospital network in Israel works according to a per-hospital balanced budget, wherein income is generated by selling medical services to the various health maintenance organizations. Therefore, any reduction in medical activity has a dramatic effect on a hospital’s income and economic integrity.
During the month that the war lasted, the reduction in the activity of the hospital had major financial implications. In general, there was a decrease in revenue-generating activities in the various disciplines (Table 3), including reductions in occupancy, in elective surgical and other interventional procedures, and in the number of deliveries. All of these changes were due to the out-migration of patients to hospitals in less-risky parts of the country, and they were exacerbated by the higher costs incurred as a result of the various emergency actions taken.
As shown in Table 3, the major impact on the hospital budget was the 40% to 60% reduction in medical and surgical hospital activities. The higher pay to workers because of the extra hours worked and the expenses incurred in the changes to hospital organizations, transportation, fortification, and so on were small and did not contribute greatly to the overall deficit incurred. Overall losses of 51 million New Israel Shekels (NIS; equivalent to $11.6 million) did not include the emergency fortification operation, budgeted by the government. The NIS 51 million loss reflects 6% of the annual hospital budget and some 50% of the monthly income to the hospital. We noted that a return to usual bed occupancy and to full operating capacity took an additional three to four weeks after the end of hostilities. This slow recovery was probably related to the natural rebuilding of elective activity together with the fact that it was late August, and both the hospital staff and the general population were taking summer vacations that had been delayed by the war. After the war, a central budget was created by the government with financial compensations to cover these losses.
In summary, in spite of the intense trauma-related activity of the hospital during the war, the hospital’s income was dramatically lower than usual, because of the necessary limitation of income-generating activities in a hospital that was under fire. This budgetary impact should be considered a major consequence of war.
Managed, Collaborative Interaction With the Media
The national and international press and other media were a major factor in this war, with online reporting to the entire world being the standard of communication. Because it is located in Haifa, which is easily accessed from all directions, and because it is the major hospital in northern Israel, the RMC was the center of the reporting of the Second Lebanon War. Hundreds of reporters from all of the national and international media stayed in Haifa (and even at the RMC itself) and continuously reported throughout the war. One serious downside of this was that, often, television broadcast teams entered the patient wards, violating the privacy of patients and interfering with the function of the medical teams.
In view of the above, we set guidelines for complying with the media on the basis of three assumptions. First, there is no physical ability to block reporters from entering the hospital and taking photographs or other informative materials from within the hospital. Second, the public has the right to be informed of the situation within the hospital, provided that patients’ rights and privacy, as well as the conduct of medical activities, are not jeopardized. Third, the hospital spokesperson and the public relations office staff are not able to fully control the overwhelming press activity.
In the light of these assumptions, the administration of the RMC took the following decisions and actions:
* They adopted a proactive approach to the press and other media, in which they provided information and encouraging reports on one side but set rules and limits to ensure the privacy of patients, as detailed below.
* The hospital spokesperson periodically provided the reporters with updates on the medical aspects of injuries and with overall reports on actions taken by the hospitals. The spokesperson was aided by the medical and logistical directors in both crystallizing the message to the public and in appearing before the public as needed. In addition, physicians and the RMC leadership, including the director, were often required to appear in various radio and television updates.
* The spokesperson of the Israel Defense Forces put in place reporters and press from the spokesperson’s office to handle communications between soldiers and the media.
* In areas of great interest to media representatives, such as the entrance to the emergency room and the helicopter landing area, reorganized spaces were designated for the use of reporters.
* All patients admitted to the hospital because of injuries, including civilian and military casualties, and their families received a notice explaining their privacy rights when approached by the press and other media for interviews.
* Television and other media teams received a similar notice with respect to the patients’ rights and the obligation of reporters to maintain patient privacy. Although these rights may seem obvious, on several occasions, thoughtless reporters offended patients and ignored their rights in order to get a story.
* Every communication team visiting the hospital was accompanied by a person from the management team or the spokesperson’s office.
Overall, in spite of occasional violations of the regulations, the communications with the press and other media went well. The hospital’s ability to function was highly commended by many experts and nonexperts who followed the hospital’s activity throughout the war. High-profile networks such CNN, ABC, and BBC, as well as the Israeli networks, disseminated the image of a well-organized hospital that worked efficiently under fire to secure the lives of civilians and soldiers.12 The extreme importance of the hospital’s continued function and its safety under fire was brought to the attention of the public and policy makers alike by the RMC’s collaborative approach to managing press coverage.
Summary and Conclusions
The management of a large tertiary care hospital that is being hit by rocket fire during wartime, that is serving a civilian population of two million, and that is the only Level I trauma center in the area under fire was an experience not previously encountered in any tertiary care academic medical center in Israel. All of the decision-making processes within the hospital were affected by inherent uncertainties, lack of data, conflicting information input, dynamic changes, and the need to respond to challenges in real time. A perspective on functioning as a physician under wartime conditions is provided by an article written by a radiology resident at the RMC, who related the personal story of working at the hospital while at the same time caring for her family at home.13
The preparedness planning and previous drills had a major impact on the ability of the team to respond to most of the challenges encountered and to continue to function in real time. This preparation included planning for scenarios involving both conventional and unconventional weapons—an example of the latter would be a chemical attack on the civilian population. The preparatory measures that had been put in place previously were fully implemented. However, the possibility of a continuous missile attack on the RMC was not anticipated, and thus ad hoc decisions were taken in response to this challenge.
The decisions that the senior administration took had a major impact on the hospital’s operations and risks. The hospital leadership took the strong position that it would continue its service to all of the population in need, becoming the backbone of their medical care. Decisions about the relocation of patients for safety reasons were taken by the leadership on several occasions throughout the war. Additional decisions had to do with managing the optimal operation of hospital personnel, providing rest periods for teams, maintaining operation of the surgical suites, ensuring continued function of the hospital laboratories, and addressing many other detailed logistical situations. The decision-making process involved ongoing consultation among the leadership team and the receipt of updates from the various civilian and military authorities. This combination of inputs led to timely decisions that were carried out promptly. In addition to the senior administration’s decisions about the logistical organization of the hospital while under fire, the medical teams had to take many medical decisions.
Recommendations for the future
Following this experience at the RMC during the Second Lebanon War, and given the continued likelihood of repeated attacks on the civilian population of Haifa, major decisions were taken with respect to standards of the fortification of the hospital’s infrastructure. The Israeli national standards have been discussed and modified on the basis of this experience in northern Israel. At the RMC, construction of an adequately sized Emergency Department that is fortified against conventional and chemical warfare and of an underground facility that can serve the RMC and, possibly, regional hospitalization needs during continuous attack is currently under way.
Advanced imaging modalities will continue to be of critical importance in the management of injury, and they should be placed at immediate proximity to the emergency room. These modalities includes FAST, CT, ultrasound, and X-ray modalities.
Whereas we used a policy of transferring patients to a less vulnerable part of Israel, as described above, it is clear that, under conditions of a general war, such a step may not be possible, and thus the occupancy of the hospital may increase rather than decrease. That development could dramatically change the workload for the hospital staff and for the systems. We conclude, therefore, that ample sheltered and fortified care-taking spaces should be prepared. One possible way of achieving this goal is to construct a fortified, underground emergency hospital.
Academic nature of the hospital
The fact that the Rambam campus is shared with the Rappaport Faculty of Medicine of the Technion made this wartime experience unique. The decision to allow teaching during the war was made by the hospital leadership and by the dean. Groups of students were part of the medical teams throughout the war. Both basic and clinical research continued, but teaching was limited to the bedside, and no classroom lectures were given. The students’ exposure to difficult trauma conditions was invaluable. Clinical research throughout the war led to several publications in the surgical, trauma, and psychiatric literature and provided important information for the medical community. It is difficult to compare the performance of the main academic campus with that of the other teaching hospitals in northern Israel, which were under similar threats and which also performed very well. The difficulty lies in the facts that Rambam is the only Level I trauma center in northern Israel and that it has unique capabilities, such as neurosurgery and thoracic surgery. Therefore, the more severe injuries were channeled to the RMC directly from the battlefield or after an initial evaluation and treatment at other hospitals.
In summary, the hospital’s experience of being under fire lasted for a full month and posed unique challenges to the hospital staff and leadership. Preparedness, leadership, and prompt, continuous, well-informed decision-making processes have been and will continue to be key factors affecting the performance of hospitals under such conditions.