Mil. Med. Sci. Lett. (Voj. Zdrav. Listy) 2015, vol. 84(2), p. 82-92ISSN 0372-7025

LETTER TO THE EDITOR

NATO ADVANCED RESEARCH WORKSHOP: HOSPITALSUNDER FIRE - PLANNING AND OPERATING A HOSPITALUNDER FIRE AND EXTREME CIRCUMSTANCES

In April 2005, an international advanced researchworkshop entitled, “Preparedness of MedicalSystems: Guidelines for Mass-Casualty Situations”was convened in Haifa, Israel, under the auspicesof NATO. Numerous specialists from variouscountries addressed the management of problems thatarise during the hospital and pre-hospital phasesof a medical response to mass-casualty situations,as well as the issue of preparedness for potentialtoxicological events. Methods for evaluating the qual-ity of care provided during such situations were alsodiscussed (1). In November 2009, the authors andtheir team organized the “NATO AdvancedTraining Course: Best Way of Training for Mass-Casualty Situations” for specialists from countriesparticipating in the Partnership for Peace (PfP) andMediterranean Dialogue (MD) programs; once again,the course was held in Haifa, Israel. The aimof the course was to inform its participants (allof whom were experienced protagonists in the fieldof emergency medical services and hospital manage-ment, or ministry of health officials, in their respective

countries) about teaching and training methods forpreparation for mass-casualty situations (2).

Throughout the next few years, the authorscontinued to exchange ideas and engage in practicalcollaborations related to similar, as well asadditional, relevant topics (3). Preparations forthe workshop’s theme, structure and content (includ-ing pedagogical, materiel and logistical support)concluded in early 2012, at which time the authorsjointly applied for a NATO grant for 2013. Afterthe application was discussed, returned for cor-rections, and finally approved by the relevant NATOcommittees in December 2013, the NATO Sciencefor Peace and Security Section awarded grant ESC(2013) 0543 ISEG.MD.ARW 984678 for theorganization of the NATO Advanced ResearchWorkshop entitled “Hospitals Under Fire:Planning and Operating a Hospital Under Fireand Extreme Circumstances”. It was decided thatthe 4-day course would take place during November17-20, 2014.

Figure 1.A lively discussion during the workshop.

Opening Ceremony

The workshop was attended by 23 experts from10 countries (Table 1). The opening ceremony washeld at the Rambam Medical Center auditorium withhospital director Prof. Rafael Beyar, and Mr. YonaYahav, Mayor of Haifa, in attendance. Prof. Beyarexpressed his delight and gratitude for the confidencevested in him to organize, in cooperation with NATO,the third such workshop during the last 9 years.This facility houses the largest Trauma Center in north-

ern Israel and, as such, has the richest experiencepertaining to situations involving mass-casualty man-agement. The hospital has been repeatedly subjectedto situations in which its security has been jeopard-ized, including rocket attacks. In light of these cir-cumstances, the board decided to build a fortifiedunderground emergency hospital capable of with-standing various forms of attack, including directmissile strikes. During his speech, Prof. Beyardiscussed the construction process, from conceptualintent to the final stages of actual implementation,which took place between 2008 and 2014. Duringthe course of ordinary daily life, Rambam MedicalCenter’s three subterranean floors serve as parkingspace for 1,500 vehicles. Should the need arise, thisvast area can be converted to a fully equipped hos-pital with 2000 beds within 72 hours. The Mayor’spresentation clearly illustrated city leaders’ interestand connection to the existence and activities of thismedical, educational and scientific-research complex.During the Second Lebanon War in the summerof 2006, the city (including the hospital vicinity) wassubjected to 34 days of rocket attacks. Unable to attendschool during the conflict, children continued theireducation via the internet and e-learning. City leadersexpropriated shopping center underground parkingareas for the purpose of (among other things)sheltering children during the day, thereby enablingtheir parents to attend work (at the hospital, for ex-ample). These measures were met with a favorable

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Figure 2.Workshop participants approaching fortified areas of the Rambam underground hospital.

Country Number

Bulgaria 3

Czech Republic 1

Italy 4

Israel 7

Netherlands 1

Norway 1

Romania 1

Sweden 2

Turkey 1

United States 2

TOTAL 23

Table 1. Country and number of participants

response, and 85% of the population remainedin the city throughout the entire 34-day attack.In another presentation, Dr. Michael Stein (Israel)and Ms. Jorie Klein (USA) commemorated the lifeand work of the late Dr. Eric Frykberg (1951 – 2013)and were joined by all participants in honoring hismemory. Dr. Frykberg was a prominent surgeon andtraumatologist at the University of Florida Collegeof Medicine (Florida, USA) and served as depart-ment head of the university’s trauma center.He authored numerous publications of great importwithin the field of disaster medicine and mass-casualty situations. He was also an excellentprofessor, and was instrumental in designingthe trauma care system infrastructure in the stateof Florida. Dr. Frykberg was a close collaborator andlecturer in both preceding workshops and was, aboveall, a highly respected colleague and friend.

Lectures

During the first presentation, Dr. Boaz Lev (As-sociate Director General, Health Division, IsraeliMinistry of Health) provided a detailed descriptionof the Israeli hospital system in terms of potentialthreats and preparedness in times of extraordinaryemergency situations. State health facilities must beon constant alert, which means that (among otherthings) each hospital must be capable of increasingits bed capacity for receiving wounded patients byapproximately 20%. Preparedness is oriented towardmass-casualty incidents, acute situations resulting

from the use of unconventional weapons (e.g. chem-ical, biological, and radiological events) and naturaldisasters. In such situations, state health services arecontrolled by a single central authority (the SupremeHealth Authority) which includes representativesfrom the Israeli Medical Corps (an Israeli DefenseForces (IDF) corps), the Ministry of Health, andthe Clalit health services organization. This close in-terdependence and cooperation between the civilianand military medical systems is key to the effective-ness of the Israeli system. During Operation Protec-tive Edge, Israel’s longest military operation to date(08.07 – 26.08, 2014), a total of 72 Israelis perishedand 2,343 were wounded. At the same time, morethan 500 acute psychological stress reactions werereported; this phenomenon should be anticipated andtaken into consideration during the course of planning.

During the next lecture, Maj. Gen. Eyal Eizenberg(head of IDF Home Front Command), discussedthe same issues from the military medical servicesperspective. Geographically speaking, Israel is sur-rounded by Arab countries comprising 270 millioninhabitants. In terms of military planning, the countrylacks strategic depth and only has limited time to ini-tiate responsive measures. Israel must, therefore,be prepared for all situations ranging from small con-flicts to full-scale war. In an effort to reduce casual-ties and infrastructure damage, several jointcivil-military systems have been developed, such as:(i) early warning, (ii) physical protection (reinforcedconstruction is mandatory in all buildings), (iii) pub-lic information and guidance, and (iv) rapid incidentresponse.

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Figure 3. Underground sector utilized as parking space during peacetime.

In an exceptionally pertinent communication,Dr. Boaz Ganor (Director of the International PolicyInstitute for Counter-Terrorism) reported on the threatof terrorism to health care systems and hospitals. Dueto their very nature, hospitals have historically beenregarded as soft targets for terrorists, whose primarygoal is to complicate, or even prevent, the deliveryof medical care. Their secondary goal lies in causingstructural damage, which means further service in-

terruptions and non-material damages associatedwith the psychological impact on the public. Duringthe years 1981 – 2013, 43 countries reported roughly100 terrorist attacks carried out against hospitals, dur-ing which 775 people perished. The presentation alsoincluded a detailed situation report regarding the ac-tivities of the so-called Islamic State (ISIS), in which10,000 foreign combatants from 60 countries (lessthan 1,000 of which originate from Europe) operate.

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Figure 4. Operating theater in action after conversion of the same underground sector.

Figure 5. General view of a Rambam underground hospital department.

Reports from Hospitals involved in OperationProtective Edge

In the next group of presentations, 3 hospital direc-tors discussed their experiences in dealing withthe issue of threats to hospitals, and their organizationand operation under war casualty conditions. Thesepractical findings stemmed from the time of Opera-tion Protective Edge. During that period, 2,648 rock-ets were fired at Israel, 578 of which were shotdown by Israel’s “Iron Dome” interceptor missiles.Hospitals in Haifa, Nahariya, and Ashkelon were pre-pared to provide treatment to an increased numberof wounded while being under threat, themselves.Joint measures undertaken at all 3 hospitals involvedsecuring hospital facilities (e.g. blast protectionfor bottle gas (oxygen), hardening electrical net-works, etc., plastic protection of windows, and mov-ing offices to secure locations).

In terms of hospital operations, less ill patientswere either discharged or transferred, and electivesurgery and outpatient examinations were cancelled;only acute surgery and oncological treatmentcontinued as normal. Each director emphasizedthe necessity of increased care for their own person-nel, who performed their duties with maximumcommitment. For example, hospitals enabled flexibleworking hours, provided employees and theirfamilies with transportation from home to school;or to the hospital and back; or provided day care for

children in the hospital itself. In addition, psycho-logical support was continuously available to allemployees, along with the possibility of extendedleave when needed. All three directors stressedthe importance of communication with the media,as hospitals tend to be under pressure from mediainterest. The media must be allowed to perform theirwork, but the simultaneous preservation of patients'rights to privacy and protection of personal data mustbe maintained (e.g., when filming wounded as theyarrive at hospital, etc.). The debriefing of individualteams after each event is equally important, as well.Staff from the Soroka University Medical Centerin Be´er Sheva confirmed similar experiences duringtheir lectures, which were presented on the final dayof the workshop.

Rambam Underground Hospital Tour

During the afternoon hours of the first day, weclosely inspected the newly-constructed fortifiedunderground hospital, including demonstrationsof operating room and intensive care unit (ICU)activities. The emergency hospital occupies threeunderground floors, has a capacity of up to 2,000beds, and ensures work continuity of the hospital,even during extraordinary mass-casualty conditions,and even when the hospital is under threat. Emergencyrooms, operating rooms, and intensive care units are

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Figure 6. Two isolation booths for high-risk infection cases.

readily available; all trauma center disciplines arerepresented to the highest degree. Undergroundfacilities also include a well-considered and pur-posefully arranged system of laboratory anddiagnostic equipment, with logistical and technicalsupport (e.g. air conditioning, independent powersources and water supply, etc.). Even when the emer-gency hospital is not actively in use, it is ina permanent state of readiness to serve as a super-specialized isolation facility for particularlydangerous situations (e.g. during cases of suspected

Ebola, etc.). In terms of the effective use of equip-ment (technological background) the principleof dual usage is applied; i.e., most of the technologyis used to ensure hospital operation under normalconditions. Aside from the economic perspective,this also ensures continuous serviceability andongoing maintenance. The underground hospitaltour held on day-1 was not only attended by ourown workshop participants, but also includeda large group of approximately 80 health careworkers from all over Israel.

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Figure 8. Prepared beds in an underground wing of Galilee Medical Center in Nahariya.

Figure 7. Artificial windows on ceilings reduce psychological stress for patients and personnel inhabiting underground spacesfor long periods of time.

Evening Lecture of the Israeli Defense Forces(IDF) Surgeon General

During an evening social event, IDF SurgeonGeneral Brig. Gen. (Prof.) Yitshak Kreiss, headof the IDF Medical Corps, delivered a particularlyintriguing presentation. After an introduction focus-ing on the concept of combat casualty care (CCC),the Surgeon General devoted the remaining timeto describing his direct personal experience withCCC implementation during Operation ProtectiveEdge. The doctrine objective is to “eliminate prevent-able death" in all those who have a chance of survival,thereby reducing the ratio between the numberof wounded and number of deaths (i.e. case fatalityrate (CFR)). For example, the U.S. Medical Corpscurrently achieves an average CFR of about 10%in Afghanistan. Thus, when creating their doctrines,the Israelis approached the task while keepingin mind the well-known fact that 90% of CCC deathsin the field are the result of hemorrhage.

The soonest possible implementation of hemo-stasis, particularly through means of a tourniquet, it isthe most crucial moment of providing first aid.

In Israel, great emphasis is placed on the practicaltraining of each individual soldier, as well as the so-called "life-saver" medics assigned to each unit.During Operation Protective Edge, of 704 wounded,a tourniquet was correctly applied in nearly 100 cases.This is clear evidence of good training of all soldiers,including reservists. Another favourable outcomepertained to the early administration of freeze-driedplasma while still in the prehospital phase.This method has been fully proven in Israel and,since February 2013, has replaced crystalloid solu-tions and is now the standard point of injury treat-ment. Of all those wounded, 67 patients (64 of whomwere soldiers) eventually died, which indicatesan achieved CFR ratio of 9.1%.

On the second day of the workshop, participantslistened to lectures. Dr. Nelson Olim, Senior Surgeonfrom the International Committee of the Red Cross(ICRC), discussed the dangers that threaten health-care professionals when fulfilling their tasks in crisisareas and situations. He gave a brief summaryof the history and development of the Red Cross,legal aspects of the Geneva Conventions, and theirapplications (e.g. humanitarian law, etc.) in practice.

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Figure 9.A physician and two paramedics: an ambulance crew prepared to render prehospital care.

There is a clear threat to medical facilities and theirpersonnel, as evidenced by the fact that 1,809 inter-national incidents (which resulted in 2,456 victims)were reported between January 2012 and December2013. The 3 most common types of attacks are (i) onhealth professionals themselves, (ii) on health carefacilities or (iii) blockage of health care accessas a whole. When compared with patients, health careprofessionals are more frequently intimidated, ratherthan killed. The aim of these actions is either to gainmilitary superiority, or to propagate terror andextortion.

Ms. Jorie Klein, Director of Trauma andPreparedness at Parkland Hospital (Texas, USA),discussed risk factor analysis models for health carefacilities, which stem from a long history of Americanhospital experience. In principle, it establishes a listof potential risks from the perspective of their impacton staff and patients, as well as potential structuraldamage and its impact on hospital operations. This isfollowed by priority planning and preparednesstraining for each risk factor. Critical thinking is nec-essary for both natural disasters (e.g. earthquakes,tornadoes, and floods), and risks inadvertently or

intentionally caused by man. Communication meth-ods are crucial, as is maintaining hospital workactivities; and it is equally important to ensureprovisions of human resources and material support,security, and infrastructure.

Dr. Mauricio Lynn, a former IDF Flight Surgeonwho currently resides and works in Florida (USA),discussed the possibilities and methods of increasingthe surge capacity of health care facilities. He em-phasized diversity in "progressively-increasingdisasters" (e.g., hurricanes, which are known severaldays in advance, and for which preparation canprogress incrementally). This is in contrast to acuteevents (e.g. earthquakes and explosions), wherethe response must be immediate. Dr. Lynn is attempt-ing to implement the Israeli system of planning, andespecially training, for such situations in health carefacilities in Florida. Such an undertaking is no simpletask in the USA, however; the economic conse-quences related to departmental disruptionsassoci-ated with training can be significant.

Ms. Sara Tzafrir, from Rambam MedicalCenter’s Division of Information Technology and

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Figure 10. Lyophilized plasma is predominantly used for volume resuscitation at the point of injury.

Communication Services, spoke to the importanceand function of computer systems during extraordi-nary circumstances. She described the hospitalmanagement computer system, which allows oneto know the precise situation at any given moment.Available data includes, for example, informationrelated to incoming mass-casualties and all aspectsof their treatment, as well as the overall situationof the hospital itself (e.g. bed capacity, material andpersonnel status). In Israel, all such computer sys-tems in public hospitals are interconnected, which isof great importance. A backup data storage system islocated off-premises, tens of kilometers away. In casesof mass disaster, incoming wounded (e.g. uncons-cious patients of unknown identity) are immediatelyphotographed upon admission and family memberscan contact other hospitals to obtain informationabout a relative’s possible hospitalization. Accessto such information is, of course, restricted to author-ized personnel.

Dr. Maurizio Foco reported on the securityof the healthcare system during mass disastersin Rome and northern Italy. Two projects currentlyunderway will result in the establishment of a majortrauma center, as well as a training simulation center.Discussions about the possible construction of an un-derground hospital are in progress.

Prof. Luke Leenen discussed his experiencewith a large underground hospital in Utrecht,Netherlands. The hospital has a capacity of up to 300beds and is in a permanent state of readiness. Only15 – 30 minutes preparation is needed prior to the firstpatient’s arrival. It is also used, as needed, in day-to-day operations when the hospital receives a greaternumber of casualties. In addition, it is utilized for stafftrainings, which are numerous, and are conductedin close collaboration with a nearby military hospital.The hospital: 1) helps identify needs in times of cri-sis, conflict, or situations of war, 2) serves Dutchcitizens involved in accidents abroad, and their repa-triation, 3) offers coordination and treatment duringmass disasters and accidents in the Netherlands, 4)provides international assistance to victims fromabroad, and 5) aids in the quarantine needs of repa-triated patients, including adequate isolation of pa-tients with, for example, suspected Ebola.

Mr. Jakob Pansell from Stockholm, Swedendiscussed the Emergo Train System method of train-ing for emergency situations; it is a simulation toolfor use in training and analyzing the capabilities ofeach department (especially the Emergency depart-

ment). It is an inexpensive tool that can be usedfor small or large groups within a department, andduring working hours. However, it does not substitutefor an actual training drill, which should alwaysoccur shortly after completion of any theoreticaltraining.

At the conclusion of this section, Prof. FrancescoDella Corte (University of Eastern Piedmont,Novara, Italy) discussed his 15 years of experienceteaching in the CRIMEDIM disaster medicineprogram. Course certificates have been awardedsince 1998, and a Master’s degree program has beenavailable since 2005.

In the following part of the program, workshopparticipants were divided into 3 work groups thataddressed specified issues (e.g. risk analysis, surgecapacity, and possible solutions for hospitals underextreme circumstances). Following a discussion andcritical evaluation, a final document was preparedfor presentation.

Field Study Trip

Practical demonstrations were organized forthe third day of the workshop and were conductedduring a visit to the Galilee Medical Centerin Nahariya. We received a briefing from the hospitaldirector, Dr. Masad Barhoum, characterizingthe particularities of their facilities, which are located9 km from the border with Lebanon and have,in the past, experienced repeated rocket attacks.In the summer of 2006, approximately 800 rocketsfell within a 1 km radius of the hospital. The facilityhas 700 beds and provides healthcare for a regionwith 600,000 inhabitants. For about two decades,they have had an underground, fortified unit with 8operating rooms, a dialysis unit, etc. In the contextof humanitarian aid, the hospital has treated 440patients from Syria, 30% of whom were women andchildren. The other three hospitals in northern Israelhave treated approximately 650 Syrian citizens.One-third of the treatment costs were coveredby the Ministry of Health, one-third by the Ministryof Defense, and one-third by the hospital itself.

Next, the group visited an IDF field hospitalin the Golan Heights providing Role 1 medical sup-port, and located directly on the border with Syria.It is positioned just a few hundred meters fromthe Blue Line, which is monitored by UN forces

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that continuously patrol the border in vehicles.Throughout the entire visit, artillery fire, grenadeexplosions, and machine gun fire could be heardfrom across the border (approximately 30 km away)in connection with battles that have been ongoing(within Syria) for the past 3 years. We were ableto examine the facilities in great detail and talk withall of the healthcare professionals, who willinglyshared their experience with providing medical carein the field. Our experiences at the IDF field hospitalreinforced the concept of good training for healthcare professionals, especially paramedics, who pro-vide first aid (including cricothyrotomy, thoracen-tesis, and hemostasis) directly at the point of injuryin the field. The staff also confirmed positiveexperiences with freeze-dried plasma infusions whenadministering first aid.

On the fourth and final day, workshop participantscontinued to work in small groups. This was fol-lowed by a collective communication presented byDr. Chen Kugel, head of the Israeli NationalInstitute for Forensic Medicine. It included a metic-ulous overview of modern methods of forensicmedicine, which enables identification of deceased

during mass disasters or terrorist attacks. Emphasisis placed on maximizing the amount of ante-mortem medical data for comparison withpost-mortem data using computer analysis. The bestidentification method is, of course, a determinationof the victim's DNA; however, this requiresthe existence of a comparison DNA sample obtainedprior to the victim’s death.

Next, we heard from Mr. David Ratner, RambamMedical Center’s Spokesman, and Director of PublicAffairs. His presentation dealt with the issue of publicinformation, and how hospitals should deal withthe media in mass-casualty situations. The optimalmethod is still being sought, but cooperation isgenerally recommended over attempting to preventmedia access. On the other hand, the media isexpected to respect certain ethical principles,particularly with regard to privacy, protected data,and the identities of the wounded and their families.In the USA and Great Britain, there is an unwrittencustom wherein the media does not publish the facesof the wounded during transport or admissionto a hospital, nor do they publish drastic, gory imagesfrom these situations.

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Figure 11. ICU bed in a Role 1 container room.

The closing lecture was presented by Swedishsurgeon Dr. Louis Riddez, who dealt with the issueof field hospitals being mobilized to various disaster-affected areas in other countries. More specifically,he discussed his own experience working withDoctors Without Borders (Medecins Sans Frontieres)in Haiti, Iran, Indonesia and Pakistan. His lecturestressed the correct timing of aid, the organizationof work after arriving on site, and collaboration withthe local health care infrastructure.

All lectures were followed by rich discussionsand an exchange of experiences among participants.After the final lecture, all 3 groups presentedthe results of their collaborative efforts from the sec-ond day. A summary of these results is expected, andwill be issued separately, as the final recommen-dations of this successful, specialized training event.

During the closing of the workshop, after a briefappreciation and acknowledgment of the organizers,both Chairmen presented certificates of participationto all participants.

Acknowledgment

The organization of this workshop was supportedby NATO Grant ESC (2013) 0543 ISEG.MD.ARW984678.

References

1.Michaelson M, Hyams G (eds): Preparedness ofHealth Systems, Guidelines for Mass CasualtySituations. A statement paper of the NATOAdvanced Research Workshop on Mass CasualtySituations. Rambam Health Care Campus, TheTeaching Center, Haifa, Israel. 2006, p 71.

2. Klein, L., Michaelson, M., Kaffenberger, W.,Hyams, G.: NATO Advanced Training Course -The Best Way of Training for Mass CasualtySituations. Voj zdrav Listy. 2010,79(3), 119-122.

3. Klein, L.: Workshop in Hradec Králové, CzechRepublic, On States of Preparedness for Mass-Casualty Situations. Military Medical ScienceLetters. 2013, 82(2), 87- 91.

Brigadier General (Ret.) Leo Klein, MD, PhD.Associate Professor of Surgery

Dept. of Surgery,Charles University Teaching Hospital

Dept. of Field SurgerySokolská 581

CZ – 500 05 Hradec KrálovéCzech Republic

E-mail.: leo.klein@fnhk.czPhone: +420 495 834 959

Fax: +420 495 832 026

Moshe Michaelson, MDTeaching Center for Trauma, Emergency,

and Mass Casualty Situations,Rambam Health Care Campus

and Teaching Hospital, Haifa, Israel

Gila Hyams, RN, MATeaching Center for Trauma, Emergency,

and Mass Casualty Situations,Rambam Health Care Campus

and Teaching Hospital, Haifa, Israel

Received 25th February 2015.Revised 25th February 2015.

Published 5th June 2015.

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