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.