Authors: Jean F. Soustiel, MD
Samuel Tobias, MD
The Galilee has been long known for the peaceful charm of its greenery and its colorful, blossoming hills. It has now been 14 years since the Israeli Defense Forces (IDF) has completely evacuated Lebanon, and eight years since the last Lebanon War. Emergency rooms of Northern Israel have almost forgotten the sight of military wounded and yet, the Galilee Medical Center (GMC) in Naharia is anything but a stranger to war. Yet, the Syrian uprising against the Assad regime has brought nurses and doctors back in time in a very particular and unexpected way, through wounded Syrians, picked up at the border and brought here by the Israeli military for medical treatment.
The Syrian uprising has entered its fourth year of fighting with a death toll of over 150,000 and millions displaced with considerable disruption to their medical services. In March 2013, two wounded Syrians were brought to the Israeli border for the first time, and since then, more than 700 have been treated in Israel, revealing the extreme distress created by the absence of modern medical care close to the conflict scene. The first step of this surreal journey for life made by wounded Syrians is to reach the border. Not since World War I has a delay in medical attention been so long, extending for several hours and often a few days during which wounded will have to survive with minimal means of life support.
For the few lucky and strong enough to reach the border, medical care will be initiated at the field hospital created by the Israeli Forces for the purpose of resuscitation and triage (Figure 1). The hospital, staffed by soldiers in uniform, includes an emergency room, an intensive care unit, an operating theater, a mobile laboratory, a pharmacy and an x-ray facility. It treats Syrian patients who cross the border regardless of creed — or of where their loyalties lie. Within the field hospital, the once-sporadic treatment of Syrian nationals in Israel has, by now, become a routine supported by the UN and relations developed between Israeli authorities and rebels representatives. Those who are well enough are sent back across the border, and those who require further treatment are referred to one of the government hospitals in Northern Israel depending on their medical needs. As the Galilee Medical Center in Naharia is the closest suitable hospital to the border, all wounded suffering from head injuries were therefore transferred to our department (Figure 2).
Since the beginning of Israel humanitarian intervention, more than 290 wounded have been brought to GMC, 60 of them suffering from head injuries and treated in our department. Among these, there were six children, four women and 50 young men, most of them rebel fighters wounded during military operations. The mean age of these patients was remarkably young (23 years). Most injuries were either caused by shrapnel or gunshot, although some of the patients were simply victims of road traffic accidents sometimes generated by a close blast. Injuries were often characterized by both their severity and their brutality expressed by gunshot wounds inflicted from a short distance indicated by a burnt entry wound as observed in a young girl shot in the forehead. In other instances, the combination of gunshot wound and separated blunt injury caused by a blow to the head severe enough to cause loss of consciousness was suggestive of an execution shot. Surprisingly, Glasgow Coma Scale scores on admission to the emergency room was around 10 with most patients being conscious during their first evaluation. This unexpected observation may be explained by the way Syrian wounded reached the border without any life support care and following a lengthy transfer so that only those in the best conditions, both general and neurological, could eventually reach IDF field hospital before being referred to GMC. Accordingly, the general outcome was unexpectedly favorable in respect with the type and severity of the inflicted wounds, probably reflecting the impact of modern neurosurgery and intensive care over WWI-type field care.
But beyond the purely neurosurgical characteristics and findings of the treated injuries, the human and psychological aspects of these injuries are likely the most intriguing and worth reporting. The first and most remarkable psychological difficulty facing the medical staff was how to adequately handle the extreme stress of the wounded who were unconscious when they arrived at our facility, and then regained consciousness in a Hebrew-speaking environment. For these Syrian fighters, the fear of yesterday’s enemy was fierce enough to generate a real panic based on the assumption that they would be treated as war prisoners. Most of the wounded brought in refrained from speaking and would not cooperate, especially when asked about personal issues. But over the course of their treatment, they learned that the staff did not mean them any harm, and surprising friendships emerged between patients and staff (Figure 3). Since then, the word of medical care delivered in Israel has spread, and rather than fear Israeli intervention, the wounded seek treatment across the border even for medical conditions that do not relate at all to the local conflict, such as hemorrhagic stroke or hydrocephalus.
The second and anticipated psychological aspect of our experience was that of the medical staff involved in a surreal situation where the patient was no longer a neighbor, but a former enemy. Although some legitimate concern arose in the hearts of hospital directors regarding the potential response of their staff to this awkward situation, the reality proved to be profoundly different as the humane tragedy of the wounded largely overwhelmed any other consideration. From this moment, our main focus was to ease our patients’ anxieties and treat their injuries. Based on the kindness shown by our physicians, some of the patients felt comfortable to share their concerns and fears for the future, like Ahmed, former personal bodyguard to Assad, who changed sides and was shot by rebels who suspected he was a spy.
Despite some hope arising from the situation created by the Syrian civil war in which both Syrians and Israelis were caught, it is very clear that this humanitarian effort to save these people’s lives is just a drop in the bucket compared to the real extent of the conflict — the end of which is not in sight. It nevertheless teaches an important lesson, reminding us that few individuals moved by human feelings may eventually triumph over hate, prejudice and despair.
From a more pragmatic and neurosurgical perspective, the outcomes of this series were unexpectedly favorable with respect to the types of inflicted wounds. This may be explained by the extremely lengthy transport of patients, often stretching for several days, therefore preventing patients with the worst injuries to reach the border. Nevertheless, these results suggest that penetrating injuries may carry better prognoses than normally assumed in some very selected patients. A better understanding of the physyopathology of wartime cranial injuries and outcomes related to their emergency surgical treatment will improve the care of future war-wounded individuals.