Code Blue In Jerusalem

The 22-year-old woman with the mane of flowing brown hair was the first victim to arrive at the hospital, and Dr. Avi Rivkind could tell within seconds that her condition was grave. Minutes earlier, a Palestinian suicide bomber had blown himself up on a crowded bus during the morning rush hour in the annexed Jerusalem neighborhood of Gilo, killing 17 passengers on the spot and wounding dozens more. Though the girl was fully conscious and had barely a scratch on her, Rivkind, 52, the head of the trauma unit at Jerusalem's Ein Karem Hadassah Hospital, instinctively recognized the signs of massive internal injuries caused by shock waves from the blast. There was a preternatural calm about her, he recalls, an eerie stillness that Rivkind has observed in many suicide-bomb victims. "You could look into the face, hear the voice, see how she was slowing down," he says. "I knew that she was burning inside."

Kneeling beside the young woman in the parking lot, the doctor gazed into her eyes and murmured a few comforting words. " 'How are you?' I asked. She looked up at me and said, 'OK.' I said, 'Don't worry, it will be all right.' I was struck by how beautiful she was." He shouted for immediate intubation--the insertion of a tube into the windpipe to create an open airway--over the objections of another doctor, who thought that Rivkind should be focusing on more obviously wounded victims. "Trust me," Rivkind told him.

A chest X-ray in the trauma unit showed an ominous "white butterfly" pattern, indicating that her lungs had exploded. Then Rivkind followed her gurney down the fluorescent-lit hallway to Operating Room 17. A team of 20 surgeons and nurses huddled around her, sliced her open and gazed in horror at the extent of her injuries: the liver as well as the lungs were heavily damaged. Blood filled the chest cavity and abdomen. The medical team brought in dozens of blood units, pumped oxygen into her ruined lungs, stopped the bleeding--to no avail. At 10:10 a.m., after two hours of frantic activity, Shiri Nagari was pronounced dead, the 18th victim of the latest act of terror. Rivkind slumped in a corner of the OR, bracing himself for a meeting with her parents. "It was the first time I have cried [after losing a patient]," the doctor says.

There is little time for tears at Ein Karem Hadassah Hospital these days. With Israel reeling from back-to-back suicide-bomb attacks in Jerusalem and a guerrilla infiltration of the West Bank settlement of Itamar that left 31 people dead in three days, Rivkind's trauma unit is back to its grim business after an unusual period of quiet. Israeli Prime Minister Ariel Sharon's Operation Defensive Shield had broken up terrorist cells across the West Bank and provided an intelligence bonanza, allowing Israel to intercept dozens of would-be bombers as they tried to cross the Green Line. But the militants have rebuilt themselves with surprising speed, and the newly formed terror cells have been streamlined, experts say, to maximize their lethal efficiency. "They have been able to radically reduce the time between recruiting, planning and carrying out attacks," says a high-ranking Israeli military officer. "It used to be a month. Now it can be a few days."

Last week's Jerusalem explosions were a terrifying indication of how Palestinian resolve has trumped Israel's military and intelligence prowess. The Gilo bus attack, which killed 19 people in all, and the French Hill bus-stop blast, in which seven died, were carried off despite advance warnings and a heavily beefed-up security force. In response, Sharon again ordered tanks into West Bank cities, this time promising to keep them there until the Palestinians renounce suicide bombing. That new strategy put him on a collision course with Defense Minister Binyamin Ben Eliezer, who has said that such military reoccupations will only deepen Palestinian despair and create more suicide bombers. The killings of three Palestinian children and a schoolteacher by two Israeli tank shells on Friday (in what Israel described as an error), followed by the murder of an innocent Palestinian man by rampaging settlers returning from a funeral, seemed to underscore the Defense minister's point. But with Yasir Arafat increasingly regarded as a spent force, and radical groups like Hamas and Al Aqsa determined to scuttle any political initiatives, the most likely short-term prospect is only more suicide bombs, Israeli military entrenchment and suffering on both sides. Already the bombers appear to have achieved one goal: the wave of terror postponed, at least temporarily, President George W. Bush's much-anticipated speech outlining his vision for reinvigorating the peace process, including the establishment of a provisional Palestinian state. "There is this feeling, 'We tried politics, we tried the Army, we tried everything'," says Ha'aretz columnist Ari Shavit, reflecting the despair felt by many countrymen. "What's left?"

The staff members at the Hadassah Hospital on the forested outskirts of Jerusalem have little time to ponder the political questions; they're too busy trying to keep people alive. That effort begins at the hospital's trauma unit, led since its creation in 1991 by Avi Rivkind, a lanky general surgeon with a Jay Leno jaw, a formidable Roman nose and a gentle yet commanding manner. In a fluorescent-lit space with six beds and a gleaming array of defibrillators, ultrasound and X-ray machines, Rivkind and his team triage victims, stabilize the critically injured, then steer them either to surgery or the intensive-care unit. "We work under the principle that we have one 'golden hour' to save a life after a severe shock-trauma," says head nurse Etti Ben-Yaacov, who has worked alongside Rivkind for 11 years. Since the latest Palestinian uprising began in September 2000, 1,800 victims of intifada-related violence, including some Palestinians, have passed through the trauma room.

Rivkind regularly encounters injuries virtually unseen before: horrific wounds to the head, chest, even rectum, caused by nails, screws and ball bearings flying at high velocity. One suicide bomber sprinkled rat poison among his nuts and bolts, which acts as an often-fatal anticoagulant. "This 14-year-old girl was bleeding uncontrollably from every one of her puncture wounds," Rivkind says. The doctor managed to stop the bleeding by using a coagulant, still unapproved by the American Food and Drug Administration, which he has since used to treat several other bomb-blast victims.

In confined spaces, the effect of the shock wave bouncing off walls and ceilings can be just as lethal as flying metal, though the damage to the body is often invisible. The worst carnage that Rivkind has ever seen occurred in a bomb blast onboard Jerusalem's No. 18 bus in February 1996. Because it was winter, the driver had closed all the windows, magnifying the blast's effect. Twenty-six died. The bus driver himself appeared unscathed, though his lungs, Rivkind later found, had been torn apart. "He gave me his name, spoke calmly--and then a few seconds later he was dead," Rivkind says.

For the Hadassah trauma team, last Tuesday morning's bus explosion was nearly as catastrophic. Ben-Yaacov arrived at the trauma unit at 6:30 a.m., she recalls, with a premonition of a terror attack. "I don't believe in God, but I felt it in my gut and my head," she says, her voice hoarsened by a regular intake of Marlboro Lights. "I started to prepare. I put antibiotics in syringes. I got ready dozens of bags of warmed blood. At 7 a.m., we heard the news." A crackling radio transmission from the Magen David paramedic team alerted Ben-Yaacov and Rivkind that a suicide bomb had gone off, this time on a bus at Patt Junction near Gilo. Rivkind took up his usual position in the parking lot and, as the ambulances arrived, began to perform triage on 21 wounded. (Dozens of those less seriously hurt were brought to other Jerusalem hospitals.)

Rivkind quickly sized up the situation: the bomb had been packed with steel ball bearings, and the enclosed space meant that many of the injured would have damaged internal organs as well as puncture wounds. A 25-year-old man was pulled unconscious from the ambulance; a steel ball had shot through his forehead and carved a path through the right lobe of his brain. A young woman was in critical condition with a crushed chest and destroyed eye. Ben-Yaacov and Rivkind finished their shift at 6:30 that evening and staggered home exhausted. The next evening Rivkind had just walked into his son's piano recital at home in West Jerusalem after another long day. Ben-Yaacov had returned home to her apartment on Jerusalem's French Hill. "I had been home for 10 minutes. I was washing my hair and then--I heard a huge explosion," she says. From her window, Ben-Yaacov looked down upon the scene--"sirens and flashing lights and bodies." She sighed, rinsed her hair and headed back to Hadassah.

Twenty-four hours after the French Hill explosion--less deadly than the Gilo attack because it occurred outdoors and the shock waves were dispersed--the trauma center was mercifully quiet. But several victims were still fighting for their lives in the intensive-care unit, including a young Israeli border policeman who had tried to tackle the bomber as he raced toward a bus stop used as a hitchhiking post by soldiers and settlers heading north into the West Bank. The man lay unconscious on a bed in the ICU, half his face burned, his arms and legs speckled by shrapnel, attended to by a team of doctors using ultrasound to determine the extent of hemorrhaging in his eyes. The cop had absorbed the full force of the blast in his chest, though the ball bearings had sprayed sideways and not penetrated his vital organs. "That's the only reason he's still alive," said Dr. Yoram Weiss, head of the ICU's respiratory team. "The next 24 to 48 hours are critical." Weiss thought it doubtful that the cop would make it.

The long-term care and rehabilitative wards at Hadassah are a grim showcase of notorious past attacks. One 3-year-old girl has been in a coma since surviving a suicide-bomb blast at the Sbarro's pizza restaurant in Jerusalem in August. Other long-term patients include a 20-year-old victim of the March 2002 bombing of the trendy Moment Cafe, in which 13 young people died, and a female Holocaust survivor who was injured in the Passover Massacre and remains in Hadassah's psychiatric ward. There have been Palestinian victims as well, including a 9-year-old boy who suffered third-degree burns over 85 percent of his body when an Israeli helicopter bombed the car he was playing in last April in the city of Hebron, and a Palestinian militant hit by sniper fire inside the Church of the Nativity.

Working intensively for two years with victims of suicide bombs has not altered either Ben-Yaacov's or Rivkind's political views. Ben-Yaacov, who held workshops in trauma care for Palestinians before the intifada broke out, calls herself a moderate and believes that Sharon's military incursions have led nowhere. "We have to try a new approach," she says. Rivkind describes himself as right-wing but says he avoids debating politics with his head nurse. "I am not going to fight a war I cannot win," he says, relaxing over a salad plate in the hospital cafeteria. And while the endless stream of victims usually prevents forming emotional connections, sometimes there are exceptions. Ben-Yaacov fights back tears when she thinks about 22-year-old Shiri Nagari, whom she briefly comforted before the Gilo bomb victim was whisked to the operating room. "Her sister came the next day. 'Please tell me, did you hold her hand?' she asked me. I had to be honest. 'No.' I said. She said, 'Never mind. I just wanted to know.' Then her father came to pick up her things--her clothes, tennis shoes, a bottle of mineral water. He said he wanted to thank me. And all I could think was, 'I don't know what we did. She died'."

Code Blue In Jerusalem | News