Us Against the World

The Israelis are good at emergency care because they have to be. It's a result of years of practice against both the missiles and mortars of traditional conflict and the maiming mayhem of terrorists. It's a mitigation against those attacks in the future. As Americans well know, the more trauma you see, the better you get at managing it. The same holds true for patient surges.

   What could be harder for Americans to understand is the psychology behind the Israeli approach. It comes from a unique set of circumstances. Israel was born after the Holocaust-after Hitler tried to wipe out the Jews. It was invaded immediately by its neighbors and has endured war and attacks throughout its existence. It's surrounded today by states both hostile (Syria, Lebanon) and unstable (Syria, Egypt), and still sees a steady stream of horrifying acts against civilians. In March there were 128 attacks, per the country's General Security Service, including a bus stop bomb that killed a tourist in Jerusalem and the stabbing deaths of a West Bank family of five-including an 11-year-old, 4-year-old and 3-month-old-in their beds.

   Taken together and repeatedly, that kind of stuff can really build an us-against-the-world mentality. Common enemies posing existential threats do a lot to bring people together. In Israel that's translated to a disciplined, coachable, participatory population with emergency response structures and mechanisms that are well-integrated, well-practiced and functional because they have to be.

   Want the mentality in metric form? The Israeli national ambulance service, Magen David Adom, has nearly 1,600 paid employees-supplemented by more than 11,000 active volunteers, half of them teenagers. The Israeli National Police force has around 28,000 officers-bolstered by another 50,000 volunteers. Imagine what a U.S. service could do with that proportion of unpaid help.

   "The Israelis' dedication and commitment to public service is really amazing," says Pittsburgh EMS Chief Robert McCaughan, who was part of the American EMS delegation that visited the country in April. "It starts at the early ages in the schools, then carries forward into the military service and afterward. They really look out for one another."

   But Americans are a bit different. By nature or at least values, we are fractious and individualistic. What the Holocaust is to Israeli DNA, "don't tread on me" is to ours. We don't feel mortally threatened, and we don't like to be told what to do. That will make some aspects of the Israeli approach very difficult to replicate here. We can borrow ideas for trauma care and surge response, but not the specter of annihilation to motivate people.

   "We saw in their eyes how seriously they approach things-there's no goofing around," says delegation member Bernard Heilicser, DO, FACEP, medical director for the South Cook County EMS system in Illinois. "There's an incredible intensity, and things are done the right way, with minimal egos. They're in it together because that's part of survival, not just so the mayor can look good at the next election."

   It's worth noting that we had a small taste of the existential threat here in America on 9/11/01. In response, we smashed up al Qaeda and constructed an entire homeland security industry in a few short years. That was a remarkable achievement, even if momentum ultimately waned, and should prompt one to wonder what America might accomplish under an interminable barrage of attacks like Israel faces.

   And if it can be achieved any other way.