Hospital Underground

Rambam Medical Center and its surrounding campus comprise one of the most important healthcare entities in Israel. It's the nation's biggest Level 1 trauma center, receiving most of its worst-injured patients, while serving as the major tertiary healthcare center in the country's north. It features a medical school and research institute, as well as a trauma teaching center and other key facilities. In 2010 it recorded around 81,000 admissions and more than 118,000 ED visits.

   During the 2006 war between Israel and Lebanon, it was also a little too close to the action for comfort. The surrounding city of Haifa, with a metro population of more than 750,000, absorbed around 100 rockets and 12 deaths. That August 13, at least 60 rockets fell within half a mile of the Rambam campus.

   None scored direct hits, but a new need was apparent. Building on the successful relocation that month of the hospital's oncology department into a vacant basement during the fighting--a move achieved in 48 hours, with full working power, water and information connectivity--Rambam officials launched construction of a new, sheltered underground parking lot that can convert in an emergency to a fully protected working hospital with 2,000 beds. The Sammy Ofer Underground Emergency Hospital will be the world's largest underground hospital facility, named after the Haifa-born tycoon whose donation helped fund it.

   When the project is completed next summer, it will provide 1,500 needed parking spaces, but in a major event will be convertible within 48 hours, with full power, water, oxygen and portable sanitary tools. The first level of the garage will feature a decontamination area, emergency department and post-trauma area. The second will have 8,200 fully sheltered square meters containing 757 beds plus staff and service space. The third will have 14,800 m2 of sheltered space with 880 beds, an OR, ICU, labor room and nursery, and dialysis center.

   Built within a headland and surrounded on three sides by the Mediterranean Sea, the facility will fully protect patients and staff from bomb blasts and chemical and biological attacks. It will be able to generate its own power and store three days' worth of oxygen, water and medical supplies.

   In the meantime, the lessons of war and terrorism inform how Rambam deals with mass-casualty events. Plans are required for all types. Rambam's 4,444 employees have standing orders and well-practiced schemes for trauma, biological, radiological and toxicological incidents in peacetime and conventional and nonconventional scenarios of war.

   Those plans are validated by an intense regimen of training. Since 2010 in particular, exercises have been larger and more consistent, with an increased medical focus and synchronized medical and nonmedical aspects. Each hospital in Israel drills regularly on areas planned in advance and rotated (e.g., a chemical event one month, an earthquake the next). This is not required by law, but a result of cooperation between hospitals.

   Medical staff must also well understand the pathologies of the threats they face--with bombings, for instance, burn and blast injuries and blunt and penetrating trauma. Suicide bombers in Israel have frequently packed their explosives with ball bearings, metal fragments, pellets and other shrapnel designed to maim. Other threats have their own considerations.

   Medically, staff have to be ready to move quickly: A 2006 review of suicide bomb attacks found the first admitted patient with ISS greater than 16 typically arrived 5 minutes from time zero, and 35% of the injured arrived in the first 10 minutes. In many major events, patients will be arriving even as hospitals are preparing to receive them. This necessitates fast activation of plans and personnel.

   Surges also require close cooperation with EMS. When an event happens, prehospital responders provide prompt notification of the time, location and mechanism of the event and the number of injured. EMS hospital liaisons track patient flow and help ensure equitable casualty distribution, while funneling information from the field to ED staffs and back.

   Rambam is also prepared for surges with a shock trauma room that can expand with spaces between beds, and extra equipment and supplies stored on portable carts for fast bedside access.

   In the Lebanon war, hospital leaders devised a new method of one-way patient flow: Patients who left the ED didn't come back. Those without physical injury were sent to an anxiety site, and the mildly hurt were segregated into a separate location for delayed treatment. That let ED teams focus on the moderately and severely injured. These were eventually dispatched to OR, ICU, imaging, wards or home, with a site set up in imaging to hold patients there for later disposition.

   At the management level, software helped track clinical and administrative needs and keep leaders apprised of patient volumes, injury types and severity in the ED and hospital. The injured were recorded in the ADAM program, a nationwide casualty identification system. ADAM interfaces online with hospitals' patient registration systems, letting them transfer data electronically, and provides information to other hospitals, police, the Ministry of Health and others on casualties both identified and unidentified. Unidentified victims are photographed and their pictures included to facilitate identification. Worried loved ones can go to any hospital in the country to search the system.

   In military conflicts there are anxiety reactions to consider as well. The Lebanon war accounted for around 2,700 Israeli stress reactions. When something big happens, psychological staff and social workers are activated along with clinical staff. So is daycare--the Israelis have found having a safe care option for their kids greatly influences whether workers will report in an emergency. For providers, mental healthcare begins immediately and brings together ED, medical and logistical staff, plus MDA in a formal, standardized debriefing process.

The U.S. Perspective

   The underground garage/hospital is a cool and novel thing--"We have options like that everywhere, and just never thought about them," notes Wingrove. But even the most advanced security measures aren't what ultimately distinguishes Rambam and other top Israeli trauma centers (such as Jerusalem's Hadassah University Hospital-Ein Kerem, with whose staff the delegation also met) from their U.S. counterparts.

   What does, for one, is training.

   "They do a lot more. The fact that each hospital does a drill every month is amazing," says DeTienne. "It's hard for our hospitals to get an annual drill in sometimes--they're just so busy and have so many other things on their minds. And to have a national drill annually, that's just phenomenal. They're certainly smaller than Montana, but even doing a state drill every year takes a lot of effort and time and commitment. And even though they have more opportunities to practice what they do, they still drill and try to learn every time."

   "When they do an exercise or education or training, everyone participates," says Stein-Spencer. "It's not just, say, your nursing staff. The other thing that's impressive, because we really don't have it routinely in our hospitals, is that they identify things right away. They debrief, and based on lessons learned, they actually implement changes. You don't hear about budget cuts or that it's too costly. If they identify a gap, they fix it. Lots of times we'll do an after-action report, but not do anything with it. We'll set those documents up on shelves and subsequently make the same mistakes again."

   Drug stockpiles and equipment caches for patient surges of course aren't uncommon to U.S. hospitals, though amounts on hand and how they're stored and accessed may differ.

   "We certainly don't have anything comparable to the preassembled supply carts designed for the bedside we saw at Rambam," says John Hick, MD, medical director for bioterrorism and emergency preparedness at Minnesota's Hennepin County Medical Center. "But to the degree possible, I think most of our hospitals have supplies available for disaster needs."

   "I have seen hospitals that have those sorts of surge capabilities and supply caches on hand," says NASEMSO Program Manager Kathy Robinson, RN. "One of the keys with public-health emergencies is being able to maintain a reasonable supply that you may never use. But having it in close proximity to the emergency department is great, if you have that kind of space."