An excerpt from Battles in White: October 7 attack: The story of the medical, nursing, and rescue teams.
Dr. Amit Frenkel is an intensive care physician at Soroka Hospital. He is married and a father of three, his wife is a psychiatrist, and his eldest son is a soldier serving in the south of the country. The family lives in Meitar, a small pastoral settlement a fifteen-minute drive from Soroka. In times of emergency at the hospital, Dr. Frenkel takes on a different role: managing mass casualty events.
In every mass casualty event, logistical preparation is of immense importance. Few deal with it as the injured arrive, but it must be considered in advance, and even while in motion. The first step is the very declaration of a mass casualty event. Who declares such an event, and what does it mean for the hospital? Declaring a mass casualty event is a formal act. It is usually done by the hospital director and requires special steps that go beyond the hospital’s routine. Similar to a country declaring war, declaring a mass casualty event means that the hospital urgently summons teams from home, and simultaneously transforms various sites to prepare for the admission of the injured.
It’s a moment that deviates from any other event in any hospital worldwide because it’s the main event for so many patients and staff members. It’s a declaration that transforms the hospital into a different place. Anyone who has never seen an ER prepare for a mass casualty event will be amazed at the immense logistical operation that arises out of nowhere, with doctors, nurses, para-medical teams, and logistics personnel arriving in droves, wearing special vests reserved only for these events. The blood bank enters a state of exceptional readiness for massive blood transfusions; the ER is cleared within a short time to make room for the injured, and whole departments discharge patients to their homes or other hospitals, all to enable treatment for dozens, perhaps even hundreds, of injured people.
On that Saturday morning, Dr. Frenkel is awakened by the sound of explosions. He understands that these are rockets coming from the Gaza Strip. Within a few minutes, he receives a message from his son in the army, in the south area. His son updates Dr. Frenkel that there was a red alert and that he and the other soldiers are protected in a shelter. Given the unusual number of alerts across the country and bits of information received on social networks, he decides to head to the hospital, where the hospital’s senior management also arrives.
Soroka Hospital employs over 5,000 staff members, many of whom live in southern towns, including those close to the border of the Gaza Strip. Messages from employees in areas where terrorists have infiltrated paint a horrifying picture, indicating a high potential for a mass casualty event, even in the early hours before a large number of injured would justify initiating a mass casualty protocol.
Dr. Amit Frenkel, deciding along with the hospital’s management to activate the mass casualty protocol ahead of time before many injured had arrived at the hospital, described the decision as a life-saving game-changer. The early mobilization of staff, as well as keeping the night shift teams at the hospital, allowed for early preparation for the event.
The change of shifts at 7:00 a.m. in most hospitals is a time when the night team hands over to the morning team, with nurses conducting an orderly shift change in all departments, and doctors ending their shifts and reporting to the incoming doctor on duty. The decision to keep the night staff at the hospital, along with the activation of the mass casualty protocol, led to over a thousand employees being present at the hospital shortly after the event began.
Dr. Frenkel wasn’t the only one arriving at those moments of uncertainty and many questions. Dr. Eitan Neeman, who was on call that weekend and intended to complete a visit, arrived at the pediatric intensive care unit. Weekend on-call doctors arrive in the morning, like on a regular workday, and stay as long as needed, with work in intensive care often not ending at a specific time. But on October 7, the hospital quickly filled with injured patients. Dr. Neeman positioned himself in the trauma room to assist in treating injured children. Shortly after, he received an urgent call and was requested to join his military reserve unit. The head of the pediatric intensive care unit arrived from home, took over for Dr. Neeman in the trauma room, and Dr. Neeman left for the military gathering point.
Dr. Frenkel and his colleagues remember the dedicated and cheerful doctor parting from them to head into a dire situation, as they were in the midst of a war that manifested not only in critically injured patients being evacuated but also in massive rocket fire threatening the hospital.
“One have to understand the problematic situation in which we must manage a mass casualty event, while simultaneously facing ceaseless alarms and rockets firing near the hospital itself,” adds Dr. Frenkel. “If in any other mass casualty event the hospital remains outside the conflict zone, here we faced two issues: an increasingly massive intake of injured, and red alert alarms that required staff protection. Unfortunately, there are areas in the hospital that are not protected, including some of the operating rooms. The staff who were outside the hospital handling the initial triage of the injured had to enter a protected area with the injured at every alarm. This naturally created difficulty in initial sorting.”
By 9:00 a.m., hundreds of doctors, nurses, and other staff members gathered in Soroka’s emergency room, starting to treat the injured who were arriving. The rate of injured arriving increased – dozens per hour from different locations, including soldiers, civilians, and attendees of the Nova festival in Kibbutz Re’im. Some arrived independently, by car. Some were evacuated by ambulances, and helicopters began to land one after another. Dr. Frenkel was responsible for managing this massive operation, including control over the emergency room and treating everyone. In the afternoon, the peak rate of injured arrivals occurred, with a record number of over 80 injured entering the hospital within the most intensive hour and more than 680 injured patients throughout the day, including over 130 in critical condition.
Several sites in any hospital are crucial for managing a mass casualty event. One is the emergency room. During a mass casualty event, the emergency room becomes entirely different. It is emptied of all “regular” patients who quickly ascend to inpatient departments, turning into an intake site for injured patients and those arriving with symptoms of anxiety.
Each type of injury has a dedicated team waiting with sheets and sequential numbers. Amid this, in addition to doctors and nurses, social workers, psychologists, and psychiatrists rush to support all those with anxiety and shock, all patients who witnessed horrors and are struggling to speak and function. Other critical sites include the operating rooms prepared to accept injured for emergency surgeries.
But perhaps the most critical site, in terms of managing the injured, is the shock room or trauma room. Adjacent to the emergency room, it typically looks like a small hall with several beds, each fully equipped with a ventilator, sets for treating severely injured patients, a monitor, and life-saving equipment. From here, after initial stabilization, the most critical patients are moved to one of three key locations: an operating room, a CT scan, or an intensive care unit.
Next to each bed in the shock room, an average of five or six team members are treating a severely injured patient. One is the patient care manager, usually the most senior doctor on the team, skilled in trauma management. This doctor is primarily responsible for the patient and determines the treatment order. Another doctor is positioned at the patient’s head, responsible for the airway, performing sedation and ventilation as needed. Simultaneously, another doctor conducts a rapid examination of the injured and also manages life-saving procedures. Additionally, at least three nurses are responsible for undressing the patient, taking vital signs, administering fluids, blood, and medications. Just one patient in the shock room can give it an appearance of constant hustle and bustle. Soroka has six such beds, prepared to handle six patients simultaneously, but it quickly becomes evident that even this is not sufficient.
Dr. Frenkel and his colleagues realize that the influx of patients, many of whom are in a critical or even life-threatening condition, necessitates doubling the capacities in the trauma room. “We add six more beds to the trauma room, reaching a situation where we are treating 12 injured individuals at any given time,” he explains. This decision was significant and helped the hospital cope with the event. “At times, we had about a hundred staff members in the trauma room, with more and more injured arriving, many of whom were then moved to surgery or intensive care,” he notes.
In all the chaos, he tries to contact his son, the soldier, in the few seconds he can spare, because personal issues cannot be entirely set aside, and in all the unimaginable moments of that Saturday morning, personal and professional lives intertwine. Dr. Frenkel’s son does not respond for many, too many, hours. And it’s not just Dr. Frenkel who experiences this, but also one of the nurses in the emergency room, whose son was called up for emergency military service and went to the front. She tries to function automatically and not think about the dangers.
Yael Dreznik is a pediatric surgeon and the author of Battles in White: 7 October attack: The story of the medical, nursing, and rescue teams.
