July 11, 2012
Israel’s fast, free and innovative way to save lives
Minutes after the words “fainting in Mamilla Mall” appeared on his pager, paramedic Arie Jaffe was defibrillating the heart of a man lying on the floor of a Jerusalem pedestrian mall.
The patient, a man in his early 60s who had been walking through the popular Jerusalem site with his grandson, was in cardiac arrest. A nurse passing by had begun life-saving procedures, but handed off to Jaffe and his partner as soon as the pair of first responders from United Hatzalah of Israel arrived at the scene. They were lucky this time — by the time an ambulance came, the patient had a steady heartbeat and was ready to be transported to a local hospital.
Jaffe is one of a vast corps of Hatzalah’s volunteer first responders throughout Israel —Jews and Arabs, religious and secular, students and professionals. Both men and women, they live and work among the population, so whoever is nearest to the scene of a call can respond. The average response time for the organization for which Jaffe volunteers is about three minutes; Hatzalah is striving for just 90 seconds.
Shortening the time between a call for assistance, the broadcast by a dispatcher and the medics’ arrival can make the difference between life and death, and Israelis’ history of suffering terrorist attacks has brought that home as much as anywhere in the world. So while Israel’s military prowess and contributions to the high-tech world are already well known, Hatzalah’s humanitarian melding of volunteerism and health-care expertise may well be its next greatest badge of courage. Applying the classic Israeli combination of technical expertise, ingenuity and doggedness, United Hatzalah of Israel is now providing an emergency response system that regularly saves lives — and is already attracting attention around the world.
The 23-year-old organization is the creation of Eli Beer, 39, a native of Jerusalem, born on the eve of the 1973 Yom Kippur War to American-born parents who immigrated to Israel in 1969. Beer said he believes spending his first month in a bomb shelter shaped the course of his life. At just 5, “I saw the first bus ever to blow up in Jerusalem — on a Friday. … It had a tremendous impact on me, as six people were killed before my own eyes, and many kids from my school were injured,” he said.
Even as a child, all Beer wanted to do was save lives, and he remembers being frustrated that there was not a better system than waiting precious minutes for an ambulance to arrive. As a teenager, he signed up to become one of Israel’s thousands of emergency medical volunteers. Soon after receiving Magen David Adom (MDA) training, he said, he was the first to arrive in response to a call for help one day, finding a 7-year-old boy choking on a hot dog. He describes a macabre scene of bystanders trying to help by picking the boy up by his feet and splashing him with water. “It wasn’t that those present didn’t want to help,” Beer said. “No one knew what to do.”
By the time a doctor arrived, there was nothing to do but to pronounce the boy dead. That was mid-1989. By the end of the year, inspired by the New York-based Hatzalah, which Beer knew of through his parents, who were then living in America, he founded United Hatzalah of Israel, wholly independent of the American version, despite the similar name. Israeli volunteers, Beer pointed out, are accustomed to dealing with the aftermath of missile strikes and terror attacks, while the Americans (there is also a very active Hatzolah organization in Los Angeles) tend to respond to calls about physical ailments, mostly within the Jewish community, traveling by ambulance rather than the ambucycle Hatzalah volunteers often use in Israel. Hatzalah’s job in Israel is to prepare patients to be transported, and the ambulances belong primarily to MDA, Israel’s national emergency medical, disaster, ambulance and blood bank service.
What Beer launched in Jerusalem in 1989 with 20 volunteers running to calls on foot now boasts 1,800 first responders nationwide, ranging in age from 21 to a 78-year old woman who lives on a small kibbutz and responds to emergencies 24/7. Hatzalah’s first-response system has become so successful that Beer is now helping to replicate the organization in other countries, including training volunteers in Panama, Argentina, Venezuela and Brazil.
In Brazil, Beer’s group assisted with the opening of United Hatzalah, creating protocols of training, guidance and equipment. Hatzalah gave the Brazilians its Life Compass technology, which guides medics to people all over the country.
For all this, Beer received a Young Global Leader award last year for his work with United Hatzalah, presented by Jordanian Queen Rania at the Davos World Economic Forum (WEF). He also received the Presidential Award for Volunteerism from Israeli President Shimon Peres. He has spoken about social entrepreneurialism at conferences in Morocco in 2010, and Davos in 2012, presenting United Hatzalah as a model for other countries to emulate. Recently, his vision and leadership skills were recognized by the WEF, which led to a scholarship to attend a WEF-sponsored management program at Harvard University’s John F. Kennedy School of Government.
To train and supply each of Hatzalah’s medics can cost upward of $5,000, and as much as $7,500 for those who are provided with defibrillators. An ambucycle costs $26,000, including the helmet, siren, medical gear, license and insurance. Despite the pressure of fundraising for an organization with an annual budget in excess of $5 million — 90 percent of which comes from charitable donations and 10 percent from the government and municipalities to support the cost of local training — Beer said he believes Hatzalah remains the only emergency medical service in Israel that does not charge for any of its services. The majority of donations come from Batya — Friends of United Hatzalah in the United States (including a recently opened Los Angeles branch) – as well as from Canada, the U.K. and France. Israelis donate 30 percent.
Many believe that Hatzalah is simply a Charedi enterprise. Indeed, Beer, himself an Orthodox Jew, sees Hatzalah as a model for training Charedi men, whose employment lags far behind their non-religious counterparts. In Israel, ending the Charedi exemption from army service and integrating of Charedim into the workplace has taken center stage — in mass rallies on the streets of Tel Aviv, in a notable Supreme Court ruling and in government debates. Beer also sees United Hatzalah as a prototype for addressing Charedi national service: “We initiated a program four years ago through which Charedim could satisfy the requirement of army duty or national service as a citizen volunteer with United Hatzalah,” he said.
I called Nissim Hassett to talk about his national service with United Hatzalah, which he did at the same time he was studying law. Now 32 and married, Hasset spoke only two hours after the birth of a son. For him, Hatzalah was the answer, he said. “The main reason I joined is because I wanted to save lives, but as a yeshiva student, I couldn’t go on to work unless I joined the army first. But the army itself isn’t suitable for the ultra-Orthodox for many reasons, including [being given time for] prayers,” Hassett said.
While living in the area of Jerusalem known as “the seam” — where east and west meet, an area that between 1948 and 1967 was a no-man’s land separating Israel and Jordan — he would regularly go on calls for Hatzalah into East Jerusalem’s Arab neighborhoods of Sheikh Jarrah and Wadi Joz, his unambiguous appearance as a Charedi Jew notwithstanding. Today, Hassett works as an intern in a Tel-Aviv law firm. By year’s end, he will take the bar exam.
Beer said more than 60 Charedi volunteers have completed their national service obligation with United Hatzalah and have then gone on to find jobs. But Beer stresses that Hatzalah, in fact, also offers a remarkable picture of cooperation among the nation’s disparate communities. In Jerusalem, for example, most Hatzalah volunteers come from the Charedi community, but secular Jews and Israeli Arabs participate as well. In Eilat, Ra’anana and elsewhere in the country, most of the volunteers are Orthodox.
For example, Murad Alian, 39, an Israeli Arab, first met Beer 22 years ago, when they trained together in the MDA medic course. Today, Alian considers himself a close friend of Beer, saying he is proud of the volunteers who work for United Hatzalah.
“Some of our volunteers work in the Old City [of Jerusalem],” he told The Media Line. “If we have a CPR [cardiopulmonary resuscitation call] we — Arabs, Charedi and secular Jews — meet each other in the house of a patient. We work in harmony, in a wonderful way, to do all the treatments together.”
Hatzalah’s ambucyles offer some advantages, too. For an Israeli ambulance to enter certain neighborhoods in East Jerusalem, it must wait to be accompanied by a military escort before it can travel to the site of the call for help. This often means it takes extra time to arrive. Meanwhile, United Hatzalah volunteers are able to respond more quickly traveling by private car or ambucycle.
Alian said that more than 80 Israeli Arabs currently volunteer for United Hatzalah, and another 30 are training to be first responders. By day, he works at Hadassah University Hospital — Ein Kerem, doing medical translations between Hebrew and Arabic.
“All our blood is red,” he remarked. “We paramedics have trained in courses together; have been at numerous scenes with multiple bus explosions. We meet up for coffee after work, and our families have visited each other.”
Beer said it’s not uncommon for one volunteer responding to a call — rushing from his synagogue to the scene of a car accident on a highway — to meet up with a second medic who ran from his mosque — with the two arriving simultaneously.
“Within minutes,” Beer said, “the two first responders, both wearing the same Hatzalah uniform, are working side by side on patients. It’s a scene more Israelis need to see.” Asked whether having men and women first responders work together has ever caused awkwardness at the scene of a call, Beer emphatically replied, “Never happens.” Currently, however, only about 50 women work in United Hatzalah, he said, because so many calls come “at 3 or 4 o’clock in the morning, and a woman can often find herself on a call where someone has died, and she would find herself all alone.”
The nature of the emergency sets the rules of conduct: “Hatzalah first responders from the Charedi community know how to respect this kind of job. They are allowed to drive on Shabbat, take care of women; it’s all for medical reasons, according to the Torah,” Beer said.
First responders also act according to their level of medical training. A paramedic, certified after two years of rigorous instruction, can perform life-saving techniques ranging from intubation (inserting an airway into a patient’s trachea to aid in breathing) to administering medications or performing field operations. Medics, on the other hand, are permitted to perform any external functions, including defibrillation and compressions and administering oxygen.
How they get the call, however, can be confusing — and Beer points to problems and rifts in Israel’s emergency response system that, ironically, United Hatzalah’s very success has revealed.
Each of Israel’s different rescue organizations and agencies has its own emergency phone number — including United Hatzalah, MDA, the police and the fire department. MDA operates Israel’s 101 emergency number, and its dispatchers send ambulances to the scene of an accident or medical emergency as the calls come in. United Hatzalah, on the other hand, uses 1221 — which has to be called independently. Many people in need call more than one number, because they are familiar with them through advertising or through word of mouth and believe that by calling two they can decrease the response time.
Competition between the two organizations further complicates some emergencies. This is where the miracle of Israel’s emergency response innovation turns messy — and, some would say, very Israeli.
Magen David Adom (Red Shield of David) is the grandfather of Israel’s emergency medical services. It was established by law in 1939, and recently it became the country’s official associate of the International Committee of the Red Cross. MDA’s size dwarfs all of the emergency medical organizations in Israel, with 1,880 full-time staff, 800 ambulances, more than 14,000 volunteers, 5,000 youth volunteers and 3.000 first response teams, including 150 motor bikes. It is also the guardian of Israel’s blood supply, according to a spokesman.
MDA’s annual budget is nearly $179 million, according to MDA spokesman Zaki Heller. Most of it is raised through Friends of Magen David Adom organizations around the world.
“The [Israeli] government purchases services [and] supplements costs for ambulances to boost their presence in sensitive areas like the northern border,” Heller said, adding that the government also pays for “extra checks on the blood, beyond what we require.”
United Hatzalah defers to MDA when an MDA ambulance arrives. But Beer maintains that MDA has been taking steps to prevent other organizations from responding to its calls, including instituting measures to prevent locations from being read off of pagers and disciplining its members who cooperate with United Hatzalah.
“Up until a few years ago, all of our EMTs [emergency medical technicians] and paramedics received all of our emergency calls from MDA,” Beer said. “Since United Hatzalah became a national organization, in order to stop our ability to expand, MDA disconnected hundreds of our volunteers from the ability to receive their emergency calls. The Ministry of Health instructed MDA to connect all of our volunteers to continue to get our emergency calls, [but] unfortunately they have still not done so.”
MDA spokesman Heller told The Media Line that MDA does not recognize Hatzalah, because MDA is denied the access necessary to certify that Hatzalah’s volunteers’ training and equipment measure up to MDA standards. He said that MDA works exclusively with its own volunteers to aid in emergencies, and he accuses Hatzalah of sometimes homing in inappropriately on MDA calls.
Dr. Michael Dor, head of the General Medicine Division of the Ministry of Health, was emphatic that MDA does not have jurisdiction to be checking other organizations. “That’s the ministry’s job,” he said.
“We have 7,000 volunteers,” the MDA’s Heller said, “and we give them a MIRS [communicator], and that’s how we call them. They [United Hatzalah] are pirating with some eavesdropping method to intercept our messages — in simple words, they are stealing our messages that we are dispatching to our 7,000 volunteers and are reaching these sites by eavesdropping or wiretapping or whatever you call it. They listen to our beepers, and that’s how they arrive. It’s not as if I’m sending them.”
The competition becomes intense at times, particularly because a first responder on a motorbike so often arrives before an ambulance, according to Beer. He said that in many cases, people call both MDA and United Hatzalah, and in other cases, a volunteer with United Hatzalah has access to an MDA pager and has relayed the call to other United Hatzalah volunteers.
Israel’s official policy is for organizations to cooperate when arriving at the same situation, according to the Ministry of Health’s Dor.
“The calls are directed to MDA, and they are in charge of the treatment. If Hatzalah gets there first, they can do the treatment until MDA arrives. Training for volunteers is a function of the Ministry of Health,” Dor said. “Both organizations are excellent, well-trained and dedicated.”
Hatzalah’s medical adviser is Hadassah Hospital’s Dr. Avi Rifkind, who through the Second Intifada — a period of unbridled Palestinian violence against Israeli targets between 2000 and 2005 — became Israel’s face of emergency medicine.
Questions of cooperation and competition between Hatzalah and Magen David Adom bring home the issue of whether Israel should institute a single, all-purpose emergency number in the image of America’s 911, or if the public is best served by having two or more numbers so the patient can choose a rescue organization.
“This question has been discussed on a number of levels of the government,” said MDA’s Heller, “and the decision was against unifying these emergency numbers. MDA’s opinion, and it is not according to the quickness of the response and the medical instructions, is that there is not to be a unified number.”
Other experts interviewed by The Media Line, including the Ministry of Health’s Dor, were unanimous in expressing preference for a single-number system.
“The ideal is one number for everyone.” Dor said.
Dr. Arye Eldad, a member of Knesset who served as surgeon general of the Israeli army from 1997 to 2000, told The Media Line, “One number is very much needed … [it’s being prevented by] political organizations trying to preserve their power.”
Asked if a single number is preferable, Dr. Jacob Assaf, head of Hadassah Hospital’s Center for Emergency Medicine in Jerusalem, was adamant: “Do you remember you’re in a Jewish country? The police, fire brigade, Hatzalah, MDA, Natali [the ambulance service that provides first aid in Israeli schools] all have different numbers. The answer is yes. If I could fulfill my dream with EMS, we would have one response center, one dispatch center … that can work with 20 organizations — some professional, some private, some national and volunteers.”
Riding with Hatzalah
I spent an evening going on calls with Hatzalah to witness how the system works. My shift began at 5 p.m. on a Thursday afternoon at a warehouse building housing the Jerusalem dispatch center. It’s a small room with multiple computer screens displaying feeds from cameras perched along roadways throughout the country. The space also houses hundreds of thousands of dollars worth of state-of-the-art lifesaving equipment.
Within minutes of my arrival, a dispatch call set us on our way: “Grossberg Street, difficulty breathing.” I traveled with three medics to the scene by ambulance [United Hatzalah owns several ambulances], and we proceeded to climb the steps of a third-floor walk-up, to an apartment where a 94-year-old woman was short of breath. While medic Chaim Attias checked the woman’s blood pressure, Yehuda Goldberg checked her pulse, and Matan Nitsky reviewed her medications. Ruling out a stroke, heart failure, blood pressure complications and neurological disorders, they administered oxygen. Fortunately, the woman required no further treatment or transportation to a hospital.
Medic Nitsky was one of my escorts that night; he’s a 26-year-old yeshiva student who is married and the father of two children. Nitsky works for both Hatzalah and Natali while finishing his studies. Six years ago, he completed 200 hours (six months) of training for MDA, learning everything from helping birth a child, to how to care for a multitude of emergency situations. Although MDA does not require in-hospital training, Hatzalah adopts the American protocol, requiring six emergency room shifts and six hospital shifts as a prerequisite to certification. Hatzalah’s policy is to include 200 hours of practical work in recognition of the reality that medics often will find themselves in a position where they will have to work alone on an emergency call.
Not surprisingly, veteran medics have their own favorite stories to tell. Nitsky recalled performing CPR in a synagogue a short distance from the seminary where he was a student. Arriving first on the scene, he came upon a man lying unconscious on the floor. “It was 6 o’clock in the morning, and there was no one else around who could help me but the man’s son. With no other choice, I told the son to help me with CPR on his own father. Right then and there, I taught him how to do compressions … on his father. I can’t imagine what the son felt doing CPR on his own father, but we saved him.”
En route to our next call — this one a three-car accident on the Begin Highway — I asked Goldberg to tell me about the most difficult case he had encountered as a medic. He described arriving to find a 1-month-old unconscious. “I came there first, we worked on her for 45 minutes, and, sadly, she didn’t make it,” he said, fighting for composure. “I was going to cry, but I had to be strong, because I had to work on her and use every minute to help her.”
In Israel, if an MDA ambulance arrives, the patient pays for the service. For Hatzalah, or any other ambucylists giving on-the-scene service, the treatment is provided gratis. Asked whether first-response organizations are worth the expense, Hadassah’s Assaf said, “It’s not [whether] they are important, they are essential.”
Explaining the importance of first responders shaving minutes off of ambulance-arrival time, Assaf said, “If there’s a cardiac arrest and the heart stops pumping, then you have minutes. If you don’t renew circulation in five to eight minutes, you have death, or irreversible damage. … In economics, we say ‘time is money.’ In cardiology, time is muscle. The earlier you treat the heart attack, the more heart muscle you save. … It’s a very significant difference if the ambulance gets there 15 to 20 minutes later. From the moment someone collapses, you need to start resuscitation within five minutes — a good, efficient resuscitation. You’ve got to know how to do it.”
Which clearly was the case with those caring medics who resuscitated the man in the Mamilla Mall. I witnessed those volunteers enter the man’s room at Shaare Zedek Medical Center just a few days later. As the medics approached their patient and all three made eye contact, it became clear why so many future medics are waiting in line: His heart was beating strong.