Dr. Raymond Rappaport of Redwood City participates in a drill during an emergency medicine course in Tel Hashomer, Israel. Photo by David Blumenfeld, special to the Chronicle
SAN FRANCISCO CHRONICLE
Sunday, November 18, 2007
Matthew Kalman, Chronicle Foreign Service
Tel Hashomer, Israel -- It wasn't a normal day for Raymond Rappaport, a veteran primary care doctor from Redwood City.
In the space of a few hours, he correctly diagnosed a postal worker suffering from anthrax poisoning and joined a team of emergency doctors to save the life of a young man with a gunshot wound to the chest. Then he entered a trauma room, covered from head to toe in a gas mask, biochemical suit and rubber gloves brandishing injectors filled with antidotes that counter nerve gas poisoning. He later worked on an unconscious patient who apparently had a seizure from a chemical attack.
Rappaport is one of 30 American doctors who recently participated in a grueling five-day course in emergency medicine hosted by Israeli civilian hospitals and military medics. On this day, the group visited the Israel Center for Medical Simulation, a state-of-the-art training center for emergency medicine at the Sheba Hospital in Tel Hashomer near Tel Aviv.
After each exercise, which was carried out using real equipment on electronic mannequins that breathed and spoke to them, the U.S. doctors watched a video playback and received feedback from Israel's top medical trainers.
"A lot of these things are not available in the United States. A lot of the medicine is different," said Rappaport. "They're up on the cutting edge of the latest technology."
As an example, he held a color-coded auto-injector that Israeli citizens use in case of a chemical weapons strike. Every Israeli is issued a gas mask and an auto-injector the size of a marker pen: white for age 10 and older, orange for age 2 to 10 and green for children under 2. The auto-injectors contain carefully calibrated doses of atropine and TMB4 that restimulate enzymes knocked out by nerve gas.
The U.S. doctors pointed out that the cocktail is not available in the United States because the Food and Drug Administration has not approved the combined dose and suggests victims of chemical weapons give themselves two separate injections.
"In Israel, we don't have the FDA so it's more useful for us to produce a combined auto-injector that has both atropine and TMB4," said instructor Arik Eisenkraft. "Why? Because we think that in case of attack it will be difficult for the casualty to understand and give himself several injections."
This no-nonsense approach impressed Rappaport.
"This is the way they get things done, the way they save lives without worrying about the bureaucracy," he said. "They go right to saving lives, making that the utmost No. 1 importance."
Rappaport, who was on his third professional trip to Israel, said he sees advances in emergency medicine with each visit.
"Americans have a lot to learn from the Israelis. Every American doctor should come on this course, so that they can be prepared and know what to do if these kind of attacks ever happen back home," he said.
Eisenkraft, a pediatrician, has been head of chemical and biological warfare medicine of the Israeli army medical corps for 10 years. He said Israelis take the threat of chemical warfare more seriously than Americans. During the 1991 Gulf War, Saddam Hussein pounded the Tel Aviv area with 39 Scud missiles. Many Israelis have prepared sealed rooms in case of a chemical or biological attack.
It's "more imminent and realistic, it's closer to us than to the United States. It's something we must know, practice and remember," said Eisenkraft. "America has great medical education, but only small groups in the Army know this stuff. Most physicians are not familiar with it."
The U.S. doctors also were introduced to Israeli strategies to deal with a sudden influx of people wounded in a mass-casualty disaster. Without planning, a rush of patients can paralyze a hospital, tying up vital equipment, Israeli doctors said. The Americans were shown how Israeli hospitals operate in groups coordinated with ambulance first-responders. Nonurgent cases are directed to other hospitals so trauma services are available for more serious cases.
Several American hospitals have adopted practices based on the Israeli model, according to Michael Frogel, chief of general pediatrics at Schneider Children's Hospital in New York.
But Israeli emergency medicine is not just about surgery.
Within minutes of a suicide bombing or another crisis, a central hot line handles inquiries from concerned families trying to locate their missing loved ones. The hot line provides updated information, including the cataloging of photographs and other details. Areas are allocated to those known as the walking wounded, victims who are suffering from shock, to keep the surgical staff and facilities free. Psychologists are called in to care for those with acute stress to prevent chronic post-traumatic stress disorder.
Solisis Lopez Deynes, a 31-year-old emergency physician at UC Irvine Medical Center, said the Israeli training had been an eye-opening experience.
"Emergency medicine here is very impressive," said Lopez Deynes, who plans to return to her native Puerto Rico to help develop emergency medical services there. "In Israel, they are dealing with emergency situations, war, explosions, suicide bombers that we don't have in the United States. So they know a lot about how to manage that, and they have to apply these techniques on a daily basis."
The Americans visited the headquarters of the Israeli army medical corps, where they joined medics training to treat serious battle injuries. They also met with emergency and disaster management experts and visited Sderot, a city of 22,000 residents that is within range of Palestinian homemade rockets. The city is under almost daily bombardment from Gaza militants.
This was the 10th training course organized by the American Physicians' Fellowship for Medicine in Israel. Frogel, who is vice president of the group, said more than 400 American doctors have acquired skills they can use back home, and some have volunteered to return to Israel during a state of emergency.
"Israel has the best system of dealing with mass casualty incidents. They have the world's finest expertise in these issues," Frogel said. "People are trying to achieve the same level of training that they have here."
This article appeared on page A - 17 of the San Francisco Chronicle
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