Boosting Resilience in Challenging Times

It takes a certain type of person to willingly rush to the scenes of medical emergencies on a daily basis and to actively treat wounded people, some of whom have severe, life-threatening injuries and require aggressive medical procedures to save their lives. Yet, even the most hardened, experienced first responders are still human and are inevitably affected by what they see and do.

Magen David Adom (MDA) – Israel's national ambulance, blood and disaster-relief service – has always been completely immersed in its mission of saving as many lives as possible. During the horrific events of October 7, 2023 and the subsequent war, thousands of MDA paramedics and EMTs have been rushing to save victims of innumerable terror attacks and missile hits throughout Israel – often putting themselves in direct danger while they are rescuing others. Their selfless devotion and professionalism during these difficult times have further boosted MDA's already excellent reputation, and the organization's employees and volunteers are proud of their essential role saving lives.

Early intervention
The organization is fully aware of the toll that this vocation can take on its devoted staffers, both employees and volunteers, and feels a deep responsibility to protect their mental health – all the more so in the last two years.

MDA staffers invariably report that the organization is like a second family. It is therefore not surprising that its members care so much about each other and are committed to safeguarding everyone's wellbeing. As such, a great deal of effort is being invested in protecting the mental health of all MDA employees and volunteers – most of whom regularly witness traumatic incidents.

"MDA is responsible for the health of its people, and not just their physical health," says Raphael Herbst, who commands MDA's reserve unit in the IDF's Home Front Command and is a leader of MDA's resilience program. He explains that today there is a much greater awareness than in the past regarding the possible impact of their work on their mental health, and Magen David Adom is committed to ensuring that its members avoid developing PTSD (post-traumatic stress disorder).

Herbst clarifies that MDA retains psychiatrists as advisors and, under the guidance of psychiatrist Prof. Haim Knobler, has put in place a program to promote resilience. "The two main principles of our program are: the earlier the intervention, the better; and the less outside intervention, the better," says Herbst.

The key element of the resilience program consists of debriefing sessions. MDA teams are expected to gather together after each potentially traumatic incident – such as rescuing wounded people from a building hit by a missile, treating victims at the scene of a terror attack, or fighting to save lives after a car crash – to discuss what happened. Each member of the team tells the others what he or she saw and felt.

"When we undergo a difficult experience on the job, we can't discuss it at home. My wife can't really understand. It's easier to talk to others from my team, who understand what I feel," notes Herbst. "In our daily work, we see horrible things. The debriefing sessions give people a feeling that the organization is behind them."

According to Prof. Knobler, the debriefing sessions are divided into two parts: in the first, each team member has to tell the others about the incident from their perspective; while the second part serves as a support group where the participants encourage each other.

The head of each ambulance team is trained to detect those who may require extra help to process a particular experience, including anyone at risk of developing PTSD. Such cases are referred to mental health professionals affiliated with Magen David Adom who can swiftly provide treatment. Herbst points out that this is important since the wait time for appointments with psychologists is typically very long in Israel. MDA staffers benefit from much faster access to mental health care – a key factor in successfully overcoming trauma. In the rare event that most members of a particular team are experiencing trauma symptoms, a psychologist will be invited to the MDA station to treat them there.

In addition, MDA has appointed resilience agents who undergo more rigorous training on the subject and are responsible for making sure that all teams are debriefed after difficult events and that those who require professional intervention receive help as fast as possible.

Highly motivated
Prof. Knobler emphasizes that most MDA personnel have high levels of resilience to start with, and the more they experience on the job, the more resilient they become. "The usual result of seeing a traumatic situation is to develop post-traumatic growth [a positive psychological transformation that can occur after experiencing highly stressful or traumatic events]. Most MDA staff members are not symptomatic, but of course some can develop PTSD. That's why we are constantly checking and why we have a system to identify them and offer help," he says.

Although there is special concern about the mental health consequences for the many young MDA volunteers, most of whom are still in high school, Prof. Knobler notes that they tend to be surprisingly resilient. "Young volunteers go through a very selective acceptance process, as demand is high to join MDA, and those who become volunteers are highly motivated and resilient. Nevertheless, we check them regularly to make sure they don't have symptoms of PTSD."

According to Prof. Knobler, the effect of a particular incident on the different members of an ambulance team can vary greatly, and it's hard to predict which events will trigger post-traumatic symptoms in which people.

"Some years ago, I was called to a scene where a mother killed her kids and tried committing suicide. It was horrible, but after a two-hour debriefing session, I went right back to work," recalls Raphael Herbst. "Sometimes, two members of an ambulance team don't have much of a reaction to a certain event, but the third paramedic can experience flashbacks. Maybe the victim reminds him of a family member," he notes. That paramedic would then receive professional intervention to process the incident.

Flood of trauma
Magen David Adom's system for dealing with traumatic experiences was originally introduced around the year 2000 during the Second Intifada. At the time, major terror attacks were almost a daily occurrence, and MDA was concerned about the effects of so much horror on their first responders. Prof. Knobler, together with Dr. Moshe Abramovich and Prof. Eli Yaffe, devised a program that required all MDA staffers who treated victims of terror attacks to gather at their MDA station for a debriefing session immediately after each incident.

"This program was actually first introduced by the US Army during World War Two," Prof. Knobler reveals. "It works best for organic groups such as an army unit or ambulance team, where everyone knows each other and works together regularly. It doesn't work as well for random people, even if they all witnessed the same potentially traumatic event." Prof. Knobler was the head of the Mental Health Department of the IDF's Medical Corps, and he brought the program to the Israeli Army as well. "The IDF's resilience doctrine came from Magen David Adom," he shares.

During the Covid epidemic, Magen David Adom boosted its resilience program following the high levels of anxiety reported by those involved with treating Covid patients. Needless to say, since October 7, 2023, there has been a veritable flood of trauma, along with a much greater need to intervene and offer care.

"October 7 was different for many reasons. Instead of remaining with their families, our first responders left them alone and saw horrible things that day. Some of us had to treat people we knew. During my life I saw plenty of terror attacks in Jerusalem, but October 7 was the most cruel of all. For the first time, MDA itself was targeted: the Hamas terrorists had instructions to destroy MDA stations and ambulances," Herbst points out.

Indeed, MDA employees and volunteers who took part in rescue operations on October 7, 2023 are still in the process of recovering from those traumatic events. On that day, MDA's call centers handled over 21,600 emergency calls – more than five times the usual volume for a regular Saturday. The men and women who answered the phone that day are also part of MDA's resilience program.

"In some cases, things are starting to come up only now," says Herbst. "Last month, we held a special therapeutic processing evening at the MDA station in Sderot. Sometimes it takes time. The war isn't over yet and there is still a real need to cope with what we see and saw."

Remarkably, Magen David Adom employees and volunteers rarely leave the organization due to PTSD or emotional stress. "They tend to continue working despite everything," confirms Prof. Knobler.

"We invest a lot of effort to ensure resilience. Our goal is that everyone will get the treatment they need in order to get back on the job and continue saving lives," Herbst concludes.

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