International Notes

Emergency Medical Services in Israel

ELI HADAS, MD,* MICKEY EISENBERG, MD, PhD,t EUGENE NAGEL, MD*

One of the first written records of resuscitation de- scribes an occurrence in ancient Israel. The prophet Elisha (II Kings 4:34) was summoned by a mother to aid her stricken child. Elisha “put his mouth upon his mouth . . . and the flesh of the child waxed warm.” Today, Israeli citizens are again resuscitated from sudden death. But instead of relying upon miracle, the latest advanced prehospital emergency care is pro- vided.

Civilian emergency medical services are the respon- sibility of Magen David Adorn (Red Shield of David), Israel’s Red Cross Society. (Blood banking services are also provided nationwide, but they are not the topic of this article.) Unlike most Red Cross Societies, which are primarily responsible for first aid training, blood donor programs, and disaster assistance, the services of Magen David Adorn (MDA) are more ex- tensive: it is the sole provider of both basic and ad- vanced ambulance care for the four million citizens of Israel, and it operates basic ambulance service from 47 stations distributed over the entire nation. In ad- dition, in 13 of these stations, mobile intensive care unit (MICU) services are also provided (MICUs bring advanced life support capability for a full range of out- of-hospital medical, traumatic, pediatric, and gyne- cological emergencies). Magen David Adorn also of- fers walk-in emergency clinics in all its stations. People with minor emergencies can receive physician care directly in the station or request a house call. The house call service is available on evenings, nights, and weekends. Furthermore, MDA provides first aid and CPR training for thousands of citizens annually and emergency medical training for medical students, doc- tors, and nurses.

From the *Medical Division, Magen David Atom, Tel Aviv, Israel, the *Department of Medicine, University of Washington, Seattle, Washington, and the *Department of Anesthesia, University of

Florida, Gainesville, Florida.

Address reprint requests to Dr. Hadas: Magen David Adorn in Israel, 60 Giborei Israel Street, 67062 Tel Aviv, Israel.

Key Words: Emergency medical services, Israel.

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Israel’s MDA began in Tel Aviv over 50 years ago purely as a first aid society. Its first vehicle and one and only “ambulance” was, in fact, a pick-up truck. There were no ambulance services in the country at the time under the British mandate. Slowly, utilizing mostly volunteers and donations, the service opened stations in other cities. During the Israeli War of In- dependence in 1948, MDA functioned as the Medical Corps of the Army. Mobile intensive care unit services were introduced in 1976 in Jerusalem, and in 1978 in Tel Aviv. Dr. Nancy Caroline, medical director from 1978- 1981, trained and supervised Israeli paramedics and began MICU services in four additional commu- nities. Since 1981 seven more new paramedic pro- grams have begun. Today, with 47 stations and over 600 ambulances (which travel 4 million miles annually) plus thousands of volunteer and paid personnel, MDA is one of the largest coordinated nationwide EMS sys- tems in the world.

Although MDA is a civilian public services organi- zation, a close working relationship with the military exists. In times of war (there have been six: In- dependence, 1948; Sinai, 1956; Six Day War, 1967; War of Attrition, 1968-1970; Yom Kippur War, 1973; Lebanon War, 1982), MDA is absorbed by the Medical Corps of the Israel Defense Forces (IDF) and assists in care and transportation of wounded soldiers. Also, because of the ever-present risk of war, MDA main- tains emergency medical shelters in all its 47 first aid stations capable of being converted into emergency hospitals for wounded civilians. Funding for MDA is primarily by donations, patient-generated fees ($12 for a basic ambulance call and $24 for MICU services, half of which is reimbursed to the patient by medical insurance), government and municipality support, and charitable contributions from overseas Friends of MDA in 13 countries (United States, Argentina, Aus- tralia, Belgium, Canada, Columbia, France, Great Britain, Italy, Netherlands, South Africa, Venezuela, and West Germany). The total budget for 1983-1984 was $25 million.

There are many similarities between MDA’s basic and advanced ambulance services and those in the

HADAS ET AL n EMERGENCY MEDICAL SERVICES IN ISRAEL

United States. The curriculum for emergency medical technicians and paramedic training is based upon the programs developed by the United States Department of Transportation. The system of dispatching is similar to the 911 systems in the United States. In most large Israeli cities, dialing 101 will connect the caller to the local MDA dispatcher. Vehicles, equipment, and med- ications are virtually identical to basic and MICU am- bulances found in American cities.

There are important differences, however, primarily in MICU services. All MICU vehicles are operated by MDA, with a physician, paramedic, and EMT-driver. The physician is responsible for diagnosis and treat- ment; thus, the role of the paramedic is primarily to assist the physician directly. Such a situation has strengths and drawbacks. Its strengths lie in the ability of the physician to definitively handle certain condi- tions and prevent the need for an emergency depart- ment visit. For example, mild congestive heart failure, mild asthma, noncardiac chest wall pain, and other conditions that are not urgent are often treated at home. Doctors are capable of administering more medications than United States paramedics, and uti- lize 12-lead electrocardiograms (rare or nonexistent in United Staes MICU services). Drawbacks occur be- cause of the rapid turnover of MICU physicians. Most of the physicians work as part of residency assign- ments or for extra work. Thus, the level of emergency training is variable and it is difficult to develop long- lasting working relationships between doctor and paramedic. It is unlikely that this doctor-paramedic- EMT team will change in the near future. In the United States, MICU services began by using physicians but soon evolved into nonphysician paramedic personnel, connected by radio to the hospital physician, owing primarily to economic considerations. The economic incentive to replace doctors with paramedics is a less

pressing problem in Israel. There is an abundance of physicians, and physicians’ salaries are extremely modest. Furthermore, and perhaps more important, there is a long tradition of MDA doctor house call services. To put it simply, the Israeli public expects a physician.

As with other MICU services in the United States and other countries, MDA’s most dramatic medical successes occur in the treatment of sudden cardiac death (SCD). In several Israeli cities where resusci- tation rates have been studied, MICU services achieve admission rates of 24% and discharge rates of 12% for SCD. These figures are comparable to those of cities such as Los Angeles.

A challenge facing MDA is the integration of its ser- vices with those of hospital emergency departments and intensive care units. Currently there is little inter- action between the prehospital and hospital compo- nents of emergency medical care. This is perhaps ex- plained by the lack of emergency medicine as a rec- ognized discipline or medical specialty and its virtual absence in academic medicine in Israel. In the United States, prehospital and hospital emergency services developed in parallel, allowing for strong interactions to occur. In Israel, hospital emergency medicine as a separate discipline, willing to assume responsibility for prehospital emergency care, has yet to evolve. There are now voices in Israel calling for emergency medi- cine to become a specialty, and the future may well see this specialty emerge.

Israel is a young country, and dramatic changes have occurred as Israel has met the challenge of ab- sorbing one and a half million immigrants and de- fending its very existence. No less dramatic changes have occurred in MDA, which began as a volunteer first aid society and has evolved into a nationwide system of basic and advanced emergency care.

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