'We Were a Step Away From Italy's COVID Crisis. How Did Israel Allow This?'

Three dead from COVID-19 in one shift, patients who languish for hours in the ambulance, impossible ethical dilemmas that must be resolved daily – a grim chronicle of the life of an Israeli paramedic

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Aharon Adler.
Aharon Adler.Credit: Emil Salman
Ayelett Shani
Ayelett Shani

Aharon Adler, can we have a brief résumé, please?

I’ve worked for Magen David Adom [emergency medical service] for 19 years. I’m married and a father of four, and live in Efrat [south of Jerusalem in the West Bank]. I used to be a lawyer, now I’m a med student. Both I and my wife are. Fourth year.

We’re speaking in the wake of a wrenching text you published. It was a description of a shift in conditions of a rampaging pandemic, with three patients who died on just that shift alone. Tell us about what you’re seeing.

I’m seeing the start of a collapse. The onset of the breakdown of a system. People are starting to reach the brink of their ability to cope – and the same goes for the equipment and infrastructure, too.

But it’s not a dramatic collapse, it’s a creeping development.

I’m talking about a gradual process. The system absorbs more and more until the bucket is full and can’t absorb the next drop.

A couple of weeks ago, Prof. Dror Mevorach, head of the coronavirus department at Hadassah University Hospital, Ein Karem, tweeted that they recently had to start deciding whom to ventilate. If this is what the start of the collapse looks like, what will it look when it peaks?

The end, which I pray we won’t reach, would be like Italy at the beginning of the pandemic – when people bring their loved ones to the hospital by themselves because there’s no ambulance or emergency service available, and leave them there at the entrance, in the hope that someone will help them, even though there is no one. We’re not there, and I fervently hope we won’t get there, but we’re one step away. There’s absolutely no doubt of that.

This week I had a patient in critical condition and there was simply no place to take her. There was no room at any hospital in Jerusalem. Finally I just took her to Hadassah, Ein Karem. They didn’t know what to do when I arrived, they were even a little angry; they asked whom I’d coordinated with and who had given me the authorization. Of course there was no bed for her. The nurse in charge was at a loss. I told her, “I’ll accept any decision you make. Tell me to leave and I’ll leave.” She looked into the ambulance and seemed on the brink of tears. “How are you going to go anywhere with her? She’ll die on the way.” And that was correct. That’s what would have happened.

In the end she just took me through a side entrance into a room. She tried to improvise an intensive care bed, scrounged a ventilator from somewhere. She said, “If she can hang on for two days, maybe a bed will become available.” If not, of course, the patient would die there, in that room. That’s the breakdown, that’s what it looks like.

As a caregiver in the field who has worked in regular times, during emergencies, in overload periods, during terrorist attacks, at the height of deadly flu seasons – I never for a moment dreamed I would see anything like this. You know, I’m the one who keeps the injured person or the patient going with all my might in order to get to the hospital with them. My job is to get them there alive, so they can be treated, and now when I arrive, I run into a stone wall.

That’s terrible.

But don’t get me wrong: That wall is people like me. People who only want to help, to save lives. But they just aren’t able to. They don’t have the means to do it.

Let’s go back to the shift you wrote about.

The truth is that, very unusually, that particular shift started quietly. I even had a few minutes to sit and talk with the crew. And then came the first call, to pick someone up at an emergency medical facility, whose location I’m not at liberty to divulge.

Then don’t. We’ll say it’s a makeshift hospital, not a provisional ward in a hospital parking lot, but a facility which at the moment is serving as a type of field hospital for older patients

We got a standard coronavirus call – a patient whose condition had deteriorated into shortness of breath. On the way we were informed that his condition was worse than they’d originally thought. We were told that we would not be able to take him to any hospital in Jerusalem, even though his condition was not stable: There was no room. They said that if his condition got absolutely critical, we should call MDA’s national medical center and they would contact the Health Ministry to find a bed for him.

Magen David Adom paramedics in Jerusalem’s Mea She’arim. Credit: Ohad Zwigenberg

If his condition is critical? Who can wait until that happens?

Certainly not a patient in his condition. The entrance to that hospital shocks you every day anew, and on that day it shocked me even more. It’s currently designated as a hospital for mildly ill patients. It has basic medical instruments, less experienced physicians. It really is a field hospital. As soon as I saw the patient I realized that he was breathing his last. We started resuscitation, intubation, medication. The doctors there mobilized to help. One held up the patient’s legs, another tried administering more adrenaline. He was a 70-year-old man who had arrived a few days earlier – he had walked in. We tried everything, even though we realized it wasn’t going anywhere. In the end we had to pronounce him dead.

We went outside, trying to take in what we had just undergone. We drove to an MDA station to pick up new protective gear and were already called back. We hurried back, and while we still putting on our protective equipment, the head nurse came out to us and said we should forget about the woman we were summoned for, because another patient was collapsing now – and to run. We ran. She was also going under. We did more resuscitation, which of course failed. We covered the deceased and said “Baruch dayan ha’emet” [“Blessed is the true judge,” recited when hearing of a death], and then I see that our ambulance driver is waiting next to the bed of the first patient, with yet another patient. The deceased patient is still lying there, covered up, and the new patient is waiting for his bed.

And he sees that.

Of course he sees it. All the patients see it. Do you understand where we are?

‘We’ve been abandoned’

We’re almost a year into the pandemic. Can you say how things have changed over time?

The deceased patient is still lying there, covered up, and the new patient is waiting for his bed. All the patients see it. Do you understand where we are?

Adler

During the first wave, people got good treatment. The second wave was harder, but the system coped. Now we’re on the brink. Look, it’s hard to really see the pandemic. It’s not like a war or a terrorist attack – it’s decentralized, scattered, hidden from the eye. I live it, so to me the picture is clear. I know we’ve reached a situation in which I’m taking critically ill patients from Jerusalem to Laniado [Hospital, in Netanya] and to Soroka [Medical Center, Be’er Sheva], because there’s no other hospital that can receive them. But the public doesn’t see that. The government doesn’t want to see it, they have more pressing matters; there are all kinds of political considerations, I don’t know. The bottom line is that there’s no response. Not from the government, not from the Health Ministry or its senior staff, whose job it is to sound the alarm. They aren’t crying out, and my feeling as a field worker is that we have simply been abandoned.

There was a report earlier this month about ambulances having to wait for hours at the entrance to emergency rooms, but nothing was said about the significance of that – about what it means when an ambulance has to wait five hours outside the ER, when there’s no one to receive the person who has just had a heart attack.

Think about a situation in which we have 10 ambulances on a shift and eight of them are waiting at hospitals. In other words, we have only two available ambulances. It’s simply incomprehensible that [the authorities] are ignoring this. What about the man who slipped in the shower and the woman who had a stroke and the motorcyclist who flipped over and the infant who’s choking and all the other things we deal with day to day? With most of our resources earmarked for the coronavirus, the routine calls have no chance of getting a good response, or even of getting an intensive-care ambulance and not a regular ambulance, which can be the difference between life and death.

On top of that, there’s the ambulance crew, who get to the patients totally wiped out, because every eight-hour shift becomes a 12-hour shift, because I waited four hours in ER and because I also helped out a little with the crazy patient overload in the hospital itself. Going with the orderly to look for a bed, helping a nurse undress a patient, because she can’t stand up any longer. I see it as a paramedic, and my wife and I also see it as medical students in the wards. The residents, who suffer from overwork even during regular times, are now coping with an inconceivable load, with wearing suffocating protective gear and with the tremendous crisis of seeing so many of the people you treat die. It’s horrific.

You and your team are exposed to the virus even more than hospital staff, because you administer first aid to people about whom it’s not yet known whether they’re sick or not.

The procedure is that the call center asks the patient about symptoms, and then it’s decided whether we need to arrive in full protective gear or just with a mask. That whole questioning procedure of course is not sufficient, and we try to take extra protective measures. I’ve had quite a few cases of patients about whom there wasn’t the slightest indication of infection, and we treated them. Among them was a man who had collapsed on the street; we resuscitated him and in the hospital it turned out he tested positive for the coronavirus.

Having to wear protective gear is a nightmare. It takes valuable time to put it all on. You see the patient fading away before your eyes – he needs a heart massage immediately, but you can’t do it without protection. Not to mention the fact that to perform resuscitation in protective equipment is hell. You don’t see anything because of the moisture inside the mask. For intubation, you have to see the opening of the trachea, and with a mask and a visor that’s almost impossible. Getting out of the protective equipment is also a whole song and dance. We are supposed to treat the equipment as though it’s contaminated. These days we do it faster – not like at the beginning – but it still takes time.

Which must have cost some people their lives.

Undoubtedly.

I had a look at protocols for emergency crews internationally during the pandemic. Airing out the ambulance for three hours after taking a COVID-19 patient, all kinds of procedures for disinfecting the ambulance and the equipment. It sounds like something you might be able to do if you were to encounter a COVID-19 patient once a week, not once an hour. That disinfection doesn’t really happen, not really.

A health professional puts on protective gear at the coronavirus ward at Tel Hashomer hospital. Credit: Emil Salman

It doesn’t happen. We try to do what we can. Do we air out the ambulance for three hours? Not even for an hour, because during an hour without an ambulance we might miss four patients.

It’s all compromises, and that’s legitimate: We’re in a war, we’re in a state of emergency, you need to know what you can forgo. But I would expect the Health Ministry to tell me what to forgo and to what extent. For the Health Ministry to tell me: Don’t send an intensive-care van for such-and-such cases anymore, don’t evacuate a patient if he’s in such-and-such a condition. Adjustments need to be made to cope with the reality on the ground, but don’t make us – the field workers – responsible.

At the end of the day, we are forced to make decisions that will remain with us the rest of our lives. Maybe I shouldn’t have taken the patient to a hospital so far away? Maybe the treatment in the ambulance should have been different? The Health Ministry already has a whole year of data. They know the probability of a COVID-19 patient in a particular condition deteriorating and dying in the ambulance if the evacuation to the hospital is going to take more than an hour. They know what the likelihood is that he will infect us if we use this or that equipment. But they’re not there. We’re alone.

I’ll tell you something now that I’m a bit wary of mentioning, but I’ll say it anyway. A 90-year-old nursing-care patient who had been hospitalized unconscious for two years in a geriatric hospital, was infected with the coronavirus. He deteriorated like crazy because his lungs were filled with fluid. Should he be ventilated? Medically there’s zero logic to it. He can’t come out of it. But he will be ventilated, until the Health Ministry issues an instruction that under certain medical conditions, or above a certain age, no activity is to be engaged in that ties down a team, a bed and resources, and which has no chance of succeeding.

Prioritization dilemma

That’s an explosive issue, especially in Israel. You have to choose your words carefully.

It’s a philosophical question, actually, a big question. I certainly don’t have answers, and I don’t know whether even in a normal situation the ideal thing would be to ventilate him, but at the moment, we’re in a state of war. There are quite a few countries that have issued instructions – and this is truly painful to hear – not to ventilate according to certain parameters. If I ventilate an unconscious 90-year-old who arrives from the nursing-care unit of an old-age home, what will I have left for the 50-year-old who will collapses an hour from now? There won’t be anything left, and the truth is that nothing was left.

Even if they don’t die in my hands, even if I succeed in stabilizing them and getting them to a hospital, even if a place is found for them, I know that tomorrow that bed will be empty. So what did I actually accomplish?

Adler

So, the prioritization dilemma is already here, and has been foisted upon the physicians and the paramedics.

Yes. I’ve already experienced quite a few dilemmas of that sort.

What are the prospects today of someone suffering from COVID-19 getting to a hospital and getting proper treatment?

The prospect of getting to a hospital is 100 percent. The question is where that hospital will be and if the patient will survive the ambulance trip. Within the hospital – that’s already another question. Staff who are keeping track of a hundred patients on monitors can easily miss a tube that’s become detached. When a patient falls in his room – and that happens all the time – it takes the staff a long time to get there. It’s not because they don’t want to, it’s because they can’t. I look at Prof. Sharon Anav [head of intensive care at Shaare Zedek Medical Center, Jerusalem], a woman I truly admire. An iron woman. Lately she looks as though she’s just finished crying and is about to start again. She’s helpless.

On that terrible shift [described above], I told a young volunteer who was with me to take a good look around him – this is the apocalypse. People are dying and we have nothing to offer them. We have reached a point where we can no longer help. I had tears in my eyes. How did we in Israel arrive at this situation? How did we allow ourselves to get to this point? What an unnecessary disaster.

I don’t know whether we allowed this ourselves. Chaotic and corrosive management brought us to this pass. The public’s behavior at this stage is at most contributory negligence.

True, but even with a failed leadership, who set the tone in the Yom Kippur War? The soldiers, not the generals.

A cynical, opportunistic government and a governmental culture of lying and deceit have a price, and it’s a [collateral , not a specific one. That’s what we’re seeing now.

True, but I still thought and believed that we would know how to overcome it. Us. The public. Every segment. It’s alright to be a little slapdash, we’re all human, but a lot more than slapdash was needed to get to our situation today.

What’s truly amazing is that when you spoke in your text about patients who died in your hands and implored everyone to be careful and vigilant, there were still people who responded with “corona liar”!

The coronavirus ward at Hadassah University Hospital, Ein Karem. Credit: Ohad Zwigenberg

On the one hand I want to pity them, on the other hand they’re the fuel of the epidemic. Because of them people are dying. There’s no question about it. They are, indirectly, simply murdering us. Some of them truly believe that they’re trying to help, but they’re killing my grandfather. They’re killing your grandfather. They’re killing us.

Let’s talk about the mental price.

The mental price – wow.

You said, ‘I’ve seen terrorist attacks, I’ve seen things in my life.”

I was a paramedic on an MDA motorcycle during all the terrorist attacks of 2015 [when there was a series of car-rammings and stabbings, but no suicide attacks]. I lived in the Ramat Eshkol neighborhood in [northern] Jerusalem, so it turned out that in the overwhelming number of terrorist incidents in Jerusalem, I was the first paramedic at the scene. My smart wife realized long before I did that there was something wrong with me. It took me a very long time to understand that I emerged from the wave of terrorism a different person from the one who entered it. Whether it’s nightmares, whether it’s edginess and a short temper. Any time I would enter a place, I would immediately think, “Hang on, where is the terrorist liable to enter from? Where is it best for me to stand so I’ll be able to try to overcome him? Where will the ambulance position itself when it arrives?”

It’s posttraumatic stress syndrome. Today I don’t experience it at the same level as I did then, but I have learned how to identify it. I learned what PTS looks like, and I recognize those symptoms again, both in me and among many of my colleagues. Especially the veterans among them.

Why especially them, and what do you see?

Because the young people don’t have the point of reference, but for the more experienced personnel, who are used to working with a functioning system and are now seeing it collapse, it’s more difficult. I see the nervousness. I see a kind of sloppy approach in work. When you’re with a patient you can’t not be 100 percent there, of course; but at the stage of the call coming in for example, I don’t see the same mobilization, the same determination, we don’t even go to the hospital with the same speed.

You become apathetic.

Yes. And that apathy is dragged with you, from the shift into private life, too.

How do you get up again for another day like that? It’s not fair that you’ve been abandoned like that.

There’s no alternative. Who’s going to do it if we don’t? We’re not going to jump ship. Prof. Ofer Merin [director of Shaare Zedek] is an inspiration to me. When I arrived with people wounded in terrorist attacks who died in my hands, he would embrace me. He’s an angel, that man. Now his eyes are moist. He looks absolutely haunted. Prof. Zeev Rotstein [director of Hadassah University Hospital], who has the nickname of the “big bad wolf” [ze’ev means wolf in Hebrew], cries in a media broadcast. If you’ve managed to break these people, that is truly a disgrace. It’s a huge badge of shame for the system.

Look, you can get used to this routine. In the end it’s very monotonous. You evacuate the sick, you look for a place for them, you cope with their family, you explain to them why he’s being taken to such a distant hospital, there is authorization, there’s no authorization, you explain why again, you start out, you care for them in the ambulance, you wait with them in the hospital until a solution is found, you disinfect the ambulance, and then it starts all over again, suddenly it’s already 3 in the morning, and soon afterward, you’re beginning another shift.

And people die in your hands. In large numbers. That’s something you can’t get used to.

You know what? Even if they don’t die in my hands, even if I succeed in stabilizing them and getting them to a hospital, even if a place is found for them, I know that tomorrow that bed will be empty. So what did I actually accomplish? Of what benefit was I?

A sense of purpose is so critical for work like yours, and from what you say, it sounds like that doesn’t exist anymore. It’s all meaningless.

That’s the hardest thing: the loss of meaning. Understanding that the work you’re doing is useless. That it doesn’t really make a difference.

What’s important for you that we should understand from your story?

People need to know that at this moment, in the present situation, what remains is only us. We have to take care of ourselves. We need to protect each another. There is no longer a large, integral, strong system that can help us. We are left only to ourselves. We are obligated to protect ourselves, because if we become infected and our situation deteriorates, there’s no one left to help us. We’re alone.

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