Scenes From an Emergency Room–October 7, 2023

Editor’s Note: Today we carry a submission received from an Israeli child-and-adolescent psychiatrist who works at Soroka Medical Center, about twenty-five miles from the Gaza Strip. In this account (translated by colleague Jennie Goldstein), Hadar Sadeh describes her experiences dealing with victims of violent trauma on October 7. As events have unfolded, we at Pulse are acutely aware that many stories on both sides of this conflict need to be told. We trust that Pulse readers find compassion for all children and families suffering the terrors of gunfire, falling bombs and lost loved ones, and the emotional wounds of an unrelenting conflict.

On the morning of Saturday, October 7, as news spreads about a terror attack, a “multiple casualty incident” code is activated at Soroka Medical Center.

My colleagues and I, experienced in dealing with small-scale multiple-casualty incidents caused by rockets, arrive at the ER and clean off our clothes, dirtied when we lay down in the road, heads covered, during periodic siren alerts on our way to the hospital.

We’ve come thinking that we’ll be dealing with a round of rocket fire like any other. As the scope of this attack becomes clearer, though, more and more of our colleagues—doctors and para health providers—appear. They come voluntarily, lacking any advance preparation from international-trauma experts or instructional webinars. The truth is, I don’t know if those could have prepared me for this.

The ER is a battlefield: Wounded soldiers, bloody stretchers, noise, unbearable smells of smoke and burned blood, an endless stream of patients we’ve never before encountered.

The patients arrive by helicopter, army jeeps, private cars riddled with bullet holes, or on foot. They fall into three groups.

First, we see the survivors of the Supernova music festival attended by about 4,000 people, and one of the first targets of the attack. These victims are mostly young adults, age twenty to thirty. Most are still under the influence of substances ingested during the festivities. (Clinically, it’s hard to distinguish between intoxication and acute-stress symptoms.) Many are elaborately tattooed and dressed in trendy clothing, now filthy from their lying hidden in the fields for hours. One woman’s white sneakers are drenched in blood from from the corpses she hid beneath. We quickly give her new shoes.

The next group to arrive is the soldiers; then, later in the evening, survivors from the border towns that were infiltrated by Hamas. These survivors avoided murder or kidnapping by hiding in their bomb shelters. They describe hearing the shouting of the attackers storming their homes and trying to break into their hiding places; some survived having their wooden homes burned around them as they huddled in their concrete shelters. Many saw family members shot. Eventually, Israeli army units arrived and rescued these survivors.

Most of the patients are wounded both physically and emotionally, so my mental-health team carries out psychiatric interventions in the midst of the ER. As we triage the patients, sirens continue to blare—a signal that rockets are targeting our town. But the entire ER is reinforced as a bomb shelter, so we continue working.

I approach a young man named Or. Restless and hypervigilant, he keeps repeating the details of the attack—a terrifying account.

He tried to escape the music festival by car, while gunmen shot at his vehicle. He jumped out and was chased on foot, passing partygoers’ bodies on either side. Hiding under a pile of leaves, he heard footsteps approaching and was sure he’d be discovered and killed—but they continued past. Or didn’t move until he was rescued by Israeli soldiers.

His words remind me of the stories about Auschwitz that my grandmother, a Holocaust survivor, shared with me and my siblings.

Or describes seeing his friends kidnapped. I can’t believe this: I’m sure that he’s catastrophizing—a stress reaction. Then he shows me a video, released by Hamas, of his friends held hostage in Gaza. I’m stunned.

How am I supposed to respond? I wonder desperately. What’s the proper intervention? This level of trauma is not described in any textbook. I’ve never learned how to treat this.

“The event is over,” I tell Or, using the words I’ve been taught. “You’re in a safe place.”

He laughs at me.

“What kind of safe place?” he says bitterly. “Any moment, the terrorists can break in here and gun us all down.”

My psychiatric preceptors have taught me to reconstruct a patient’s past and build a chronology of events—past, present, future. But how can I build a coherent narrative with patients who face so much uncertainty? When they don’t know where their family members are—whether they’re dead, wounded, kidnapped? And where do they go from here? Do they even have a house anymore? A community?

In our trauma trainings, my colleagues and I have been taught to offer hope. To be honest, right now that’s very hard to do—because we ourselves don’t feel hope. There’s a sense that our familiar protocols are gone. Irrelevant.

So we rely on our clinical instincts. We use lots of cognitive reframing, guiding patients to tell their stories in a way that emphasizes their bravery and resilience, by pointing out how they drew on inner strengths and resources.

A Bedouin family of sixteen arrives with acute stress symptoms following a rocket explosion in their village. An Arabic-speaking psychiatric resident gathers them for a group therapeutic intervention. Our occupational therapist takes the younger children aside and blows bubbles with them as a relaxation technique.

Much of our work is not clinical but practical—taking care of human needs. Making sure that people have clean clothes. Providing contact-lens solution for a soldier whose dry lenses are irritating his eyes. Reuniting patients with family members taken to other hospitals. Responding to the people who converge on our ER with pictures of missing loved ones. Holding their anger and frustration, which is sometimes directed at us: A missing soldier’s parents yell at me that the missing-persons  hotline has crashed. Staying beside children who arrive with gunshot wounds—children whose parents were murdered before their eyes—so that they won’t be alone.

In the ER, an unidentified soldier lies motionless, mute, almost catatonic. He doesn’t eat or drink. Once in a while, he sheds tears. Because he doesn’t speak, he can’t be identified. Our attempts to ground him by telling him where he is and how he got here, and using sensory stimulation—wetting his parched lips, massaging his hands—have no effect. An injection of antipsychotic medication doesn’t help. He is hospitalized on the internal-medicine ward. The next morning, more alert, he identifies himself; his family arrives, and he is discharged.

We hear story after story. Horror stories. It is hard to absorb. We feel despair. Fortunately, at night a group of close staff remains, and we support each other. We meet with patients in pairs, because it’s too overwhelming to do it alone.

A nurse turns to me in tears. “Can you please give me a sleeping pill?” she asks. “I’m afraid that I won’t sleep, after everything I’ve seen and heard.”

My colleagues and I understand that our job also involves taking care of the ER staff. We circulate among them, reminding them that we’re here for them.

Toward morning, an elderly couple arrives from the town of Ofakim, where they were held hostage for almost twenty-four hours.

“Is this real?” the wife asks me over and over. She tells an incredible story, describing how she kept feeding the assailants holding guns to her head, to keep them from killing her and her husband, until the police finally arrived and rescued them. Telling her story, she laughs with relief.

“She’ll be fine,” the on-call resident and I say to each other.

When morning comes, I return to my car. Only then do I burst out crying.

I cry the whole way home to my children.

It will take me several days, and a lot of support from my dear, experienced colleagues, to replenish my inner strength enough so that I can return to offer my support—with hope.