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Personal view

The experience of a battalion physician in the Yom Kippur War Itzhak Brook ABSTRACT A medical officer’s tasks during wartime are especially complex and difficult. This article describes the numerous challenges faced while serving as a battalion physician in the Israeli Army during the 1973 Yom Kippur War. I had to take care of the medical and psychological needs of the hundreds of soldiers in the battalion and also needed to ensure the health of my own medical team so that we could effectively serve those on the battlefield. At the same time, I had to deal with my own anxieties and fear as I experienced the high human cost of war. I also had to constantly assess our strategic situation; be informed of and anticipate future events; make sure that the medical team acted appropriately in the field; be a role model to others; practice preventive medicine; deal with my soldiers’ fears, anxieties and post-traumatic stress; be always available to those in need; improvise when needed and maintain my compassion for human life— even when the life was the enemy’s.

INTRODUCTION The tasks of a medical officer are especially complex and difficult during times of war. As a medical officer in the 1973 Yom Kippur War, I learned many important lessons serving as the only physician of a reserve supply battalion.1 The war was fought in October 1973 in the Sinai Peninsula and Golan Heights between Israel and an Arab Alliance principally of Egypt and Syria. My battalion of approximately 280 supply vehicles (trucks and gasoline and water tankers) and 700 soldiers supplied a reserve Armoured Corps division in the Sinai desert with ammunition, fuel, water and food. These soldiers risked their lives as they worked under enemy fire, replenishing tanks with fuel and providing fighters with weapons and ammunition. I watched them as they performed their mission, overcoming seemingly insurmountable obstacles despite constant danger, as they dealt with their fears and anxieties. Many of them paid the ultimate price. It was a daily struggle Correspondence to Cdr Ret USN Itzhak Brook, Department of Pediatrics, Georgetown University, 4431 Albemarle St. NW, Washington DC, 20016, USA; [email protected]

for survival, requiring a resourcefulness and performance that few had ever experienced. Early on, I was struck by our inability to control the ever-present danger, the uncertainty and unpredictability of our future and, constantly, the fog of war. We had no ability to deal with the continual bombardment from long-range artillery, missiles and repeated aerial attacks— let alone predict when they would occur. Many casualties were due to the simple (and perhaps avoidable) fact of being in the wrong place at the wrong time. This manuscript describes my personal challenges and experiences during that war. I had to take care of the medical and psychological needs of the hundreds of soldiers in the battalion, and also had to ensure the health of my own medical team of four medics and an ambulance driver, so that we could effectively serve those on the battlefield. At the same time, I had to deal with my own anxieties and fear as I experienced the high human cost of war.

CARING FOR SOLDIERS Caring for the soldiers involved treatment for war-related trauma, as well as medical and psychological issues; because the battalion was tasked with providing ammunition and fuel to the front line, the men were exposed to near-constant risk of injury from artillery, missile and machine gun fire. In the most tragic events, several trucks sustained direct hits and their drivers burned to death before they could be reached. Having to triage the injured according to the seriousness of their injuries required rapid decision making under difficult conditions, while providing immediate care to those with severe trauma. At times when there were multiple victims, only palliative care could be provided to those who were not expected to survive, while directing resources to those who were expected to live. Making such decisions resulted in an enormous emotional strain, which I tried to avoid whenever possible by helping everyone I could. Common injuries included burns, fractures, cuts and bruises, crush injuries and penetrating bullet and shrapnel wounds with severity varying from minimal to Brook I. J R Army Med Corps Month 2014 Vol 0 No 0

multiple organ failure and life-threatening wounds. Acute care was given by cleaning and bandaging wounds and burns, stabilising suspected fractures, providing airway resuscitation and administering intravenous fluids, analgesics, narcotics and antibiotics. Those who sustained penetrating chest wounds required intubation and sealing the site of the injury; penetrating abdominal injuries required wound care, intravenous fluid and antibiotics, and limb injuries with severe bleeding necessitated a tourniquet, wound care and intravenous fluids. Individuals with mild injuries were able to return to their duties, while men with serious or life-threatening injuries were evacuated to the closest field hospital. The most frequent medical issues were gastrointestinal ailments (such as diarrhoea, indigestion and constipation), colds and headaches, but because the battalion was comprised of individuals from 30 to 45 years of age, many men had chronic medical conditions, such as arthritis, duodenal ulcers, mild hypertension and angina, which also required attention. Finally, the repeated return to the front line to provide ammunition and fuel to the fighting forces and re-exposure to imminent danger took a significant psychological toll, even on those who had not suffered physical injuries or medical illness. This was particularly difficult as the fuel and ammunition supply trucks were susceptible to enemy fire and many of those soldiers needed counselling for their anxiety and fear.

PREVENTING ILLNESS AND INJURY In addition to being a battlefield physician tending to the illnesses and injuries of individual soldiers, I also needed to serve as an epidemiologist and public health physician to safeguard the overall health of our troops. In one case, an unusual presentation during a routine sick call led to the prevention of a major medical problem in the fighting units1: two soldiers came to see me presenting with abdominal pain and diarrhoea, and after denying having ingested contaminated food or water, they both noted that the water they had recently drunk smelled like gasoline. When I asked them to open their canteens, the odour was overwhelming. Within 15 min I was able to locate the source of the contamination—a gasoline tanker truck that had been inadvertently filled with water. This vehicle was about to leave for the front lines, where it would have furnished water to hundreds of soldiers in the midst of the fighting. I could only imagine the consequences of 1

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Personal view thirsty tank crews drinking gasolinetainted water during a battle—abdominal pain and diarrhoea could have incapacitated them, making it difficult or impossible to carry out the mission.

CARING FOR WOUNDED ENEMY SOLDIERS Caring for wounded captured enemy soldiers is challenging. I took care of several wounded Egyptian soldiers, providing them with the same level of treatment that I gave my own injured men.1 While my natural instincts and years of medical training urged me to help any wounded warrior to the best of my ability, I could not deny the feeling of animosity toward the enemy in the heat of battle. I managed to overcome these misgivings, however, in the hopes that our captured soldiers would be treated as well as we were treating the Egyptians. Caring for these enemy prisoners of war humanised our adversary to me, and I felt inner satisfaction that I could still honour the sanctity of the human life, a value with which I had been raised.

DEALING WITH FEAR, ANXIETY AND POST-TRAUMATIC STRESS DISORDER Coping with fear and anxiety under fire is one of the most acute problems a medical officer must face.2 3 He has to counsel fellow soldiers and also has to deal with his own anxiety and fear. I continuously faced these issues during the Yom Kippur War.1 2 The sudden and unexpected circumstances that led to the war and the initial setbacks experienced by our military increased the psychological strain on everyone. Israeli soldiers were not accustomed to being passive and to absorbing the blows inflicted upon them without being able to remove the source of the danger. The fact that we had little or no information about our military situation aggravated the stress on our soldiers, while the unpredictability of the numerous casualties made a terrible situation even more difficult. We understood that if we had been mobilised earlier, our situation would have been entirely different—and much better.3 4 We soon also realised that we could no longer trust the information broadcast over the Israeli radio, upon which we obsessively relied, as it was often misleading or incorrect. As the fighting raged on, many soldiers began coming to me presenting with anxiety, fear and the inability to cope with increasing pressure and danger; some requested tranquilisers like diazepam, which I was reluctant to administer as it would have impaired their ability to drive 2

and make decisions. I was unprepared to address these issues. My officer training for physicians (which I had completed a few years earlier) did not cover the topic of recognising or treating post-traumatic stress disorder.3 This lack of training might have been because Israel’s previous two wars were short and victorious—no one was prepared for a longer war in which we did not have the initiative; no one was ready to deal with soldiers who faced the possibility of defeat. Furthermore, just to admit fear was taboo in Israel’s ‘macho’ society. The way I initially dealt with soldiers who confessed to being afraid was to dismiss their claims and advise them to be tough and strong and go back to their duties. Put simply, this advice did not work. In fact, I was also experiencing the same feelings as these soldiers, but was too embarrassed to admit it. How could I not feel fear? We were being bombarded with heavy artillery, fired upon with longrange missiles, strafed by warplanes and attacked by Egyptian commandos. It eventually dawned on me that fear was a natural reaction. I also realised that fear can be one’s friend if it makes one cautious and careful. The three natural reactions to fear are to either run away, freeze or attempt to eliminate the source of the danger. It seemed plausible that the Egyptians were also afraid; but if we wanted to survive and win, we would have to perform despite being afraid. I began openly discussing their fears with my soldiers by first confessing my own anxieties. I assured them that feeling fearful is a normal reaction to danger and that being afraid does not make them less manly. There was tangible relief on their faces and in their body language. I proceeded to tell them about the choices one can make to cope with one’s fear. Most men felt better after the conversation and were able to return to their duties. I prescribed anti-anxiety medication to a few individuals, while a few others had to be kept away from the front or even be evacuated. In the end, legitimising their fears turned out to be the most effective way to help my soldiers. One of my earliest challenges was dealing with the anxiety and stress disorder experienced by one of my medics. On the fourth day of the war, he suddenly started to exhibit bizarre behaviour. He would stay up all night and remain on watch, even when his shift was over. Consistently anxious, he was convinced of an unseen danger and he became

increasingly agitated and disconnected from the reality around him. I thought that I could help him get over his anxiety, so that after the war was over, he would not have to live with a feeling of failure. I listened to his worries and when he told me about his irrational assessments of the dangers we were facing, I assured him that things were not as bad as he thought. I resisted my budding assessment that the best thing would be to evacuate him as I did not want to lose one of my four medics, and I hoped that he would adapt to the situation. Selfishly, I felt that letting him leave would be a personal failure. Unfortunately, my medic collapsed 3 days later and had to be evacuated. I felt guilty that by letting him stay I contributed to his mental collapse. I realised that I had misjudged my ability to effectively help him by keeping him close to me and later understood that my failure to help him was due to my inability both to speak openly about the validity of his fears and to reassure him that it was normal to be afraid. By not validating his anxieties, I left him as the only one among us who openly expressed his fears. Even though I also felt afraid at times, I kept my thoughts to myself.

AVAILABILITY FOR THE SOLDIERS Being available for the soldiers at all times is very important, and can send a message that assistance is there whenever they need it. It is especially important during periods of intense stress.5 Although I conducted a daily sick call, I also decided that whenever possible I would visit the four companies in our battalion every morning,1 thinking that by visiting on a daily basis I would be more available to the soldiers. These visits were helpful and I felt that the risks of making these trips were justified since many soldiers would have not been able to see me if I had not shown up in person. This was partially due to the fact that our battalion had to change locations every few days and also because the soldiers were busy with duties that often demanded long drives. During these visits to the troops I got to know more of the men. I soon realised that most of those who came to see me just wanted to chat a little. I was also able to abort medical problems at their inception and prevent further development. These trips also enabled me to obtain firsthand information about the situation on the battlefield. As it turned out, the truck drivers who made daily trips to the front to supply the tank brigades were the most informed in our battalion. Brook I. J R Army Med Corps Month 2014 Vol 0 No 0

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Personal view I also walked among the battalion’s trucks on the day that we crossed the bridge over the Suez Canal into Egypt. Even though the area around the bridge was being intermittently bombarded, I was hoping to spot soldiers who had been too busy to see me or who had not known how to find the medical unit. I was also hoping to lift the spirits of our men, hoping that by seeing me they would feel better knowing that I was around. Suddenly, a Katyusha rocket exploded nearby and I was wounded in my leg and skull. In retrospect, my leaving the medical unit’s protective trench was not wise, as I exposed myself to undue risks. After bandaging my wounds myself, I remained with my unit and kept taking care of injured soldiers. Sixteen hours later, my condition had worsened and I was told by the field hospital surgeon that I had to be evacuated. I initially resisted his advice. I did not want to abandon my soldiers and leave the medical team without a physician. I was aware, however, that my injuries required treatment that is not available on the battlefield. I felt a mixture of guilt and relief when the helicopter evacuating me along with other wounded soldiers (some whom I had previously treated) lifted from the ground. I was happy to learn later that a replacement physician arrived at my battalion a short time later.

PRESERVING THE MEDICAL TEAM I was acutely aware that caring for the physical and mental health of the soldiers in our battalion depended on the survival of our medical team. This principle was repeatedly stressed during the medical officer’s course that I had completed 3 years prior to the war. Accordingly, I had to constantly assess the safety of our team’s location and the overall military situation and be informed about any potential dangers. Since we had no radio communication, my assessments were based on what I could see and hear, my common sense and my instincts. Whenever possible, I selected locations for the medical team outside the range of the enemy’s artillery or hidden from their direct view. I also tried to choose sites accessible to potential helicopter landings to allow for quick evacuation of the wounded. To my surprise, the ‘fog of war’ was pervasive, and during much of my time on the battlefield I was forced to operate without direct instructions.1 Consequently, I relied on my general knowledge about methods of firing and range of operation of artillery, Brook I. J R Army Med Corps Month 2014 Vol 0 No 0

aerial bombing strategies and common sense. While I received some guidance from the commanding officer, there were numerous instances when I had to make my own decisions. Fortunately, I was able to learn useful information from the soldiers I treated and from others we encountered. My goal was to be informed and to anticipate future events as much as possible. Because I was often separated from the command unit by great distances, many directions and orders reached me long after they had been issued. Moreover, due to the fluid, constantly changing nature of the military situation, many orders, once they arrived, either did not make sense or were obviously inappropriate. I always reassessed these orders in light of the current situation. This sometimes meant that I had to modify them, or change my responses to ensure the successful performance of our mission and our survival as a medical team. One such incident occurred when our battalion was en route to the Suez Canal. We were proceeding on a narrow and crowded road, the only way to reach the bridge that had been constructed across the Canal. At one point, I was ordered to drive from the rear of our 280-vehicle convoy to its head, as several vehicles had been hit by enemy fire and needed medical assistance. We immediately proceeded forward, passing other vehicles in the long convoy as rapidly as we could. However, our progress was very slow and within a short time we were unable to continue due to heavy artillery bombardment hitting the road and setting trucks on fire, resulting in passengers fleeing in all directions. My ambulance was an improvised civilian van and could not be driven on the sand dunes that lined the road. Accordingly, I instructed our medical team to take cover in the dunes until the fire had subsided; when the bombardment continued, I elected to retreat to a safe distance until conditions improved. While it was a difficult decision to delay our arrival when we were sorely needed, I made the judgment that not waiting would have only resulted in more casualties. Fortunately, the wounded we had been called upon to help were taken care of by another medical unit that was close by. In retrospect, my decision to retreat saved our medical unit from disaster, as the site from which we had retreated was heavily bombarded. Many of the vehicles that did not retreat were destroyed and their passengers injured or killed.

MEDICAL TEAM MEMBERS ARE ALSO SOLDIERS I never lost sight of the fact that the members of my medical team were soldiers; they had to be able to defend themselves if necessary. The enemy certainly could not differentiate us from regular soldiers. I, therefore, insisted that my medics carry their rifles and wear their helmets at all times and tried to serve as a role model by always following these rules.1 In fact, on several occasions, we were in direct physical danger—from shelling, long-range missiles and aerial attacks —and had to respond appropriately. While our battalion was deployed over vast areas, I made daily drives to visit all the truck companies within the battalion. Because we were at risk of being ambushed by Egyptian commandos, I made sure that we always had our weapons loaded and hand grenades available for use. These drives illustrated the anomalous situation faced by our medical team. I knew that we would return fire directed at anyone attacking our vehicle. Yet I also knew that, once the shooting would be over, we would care for any enemy soldiers we might have injured. This was a strange dichotomy: recognising that we may need to kill in order to stay alive and that we would be caring for anyone we had tried to eliminate us minutes earlier. Fortunately, these drives were completed without incident.

IMPROVISATION Doing the best you could with what you had was essential in those difficult and challenging conditions. We had not received adequate medical supplies or equipment and had to make do with only four containers of supplies, compared with the six we had during annual manoeuvres. Moreover, what supplies and equipment we had were deficient in both quantity and quality. We were missing intravenous infusion bags and sets, bandages, and medications, as well as enough intubation and resuscitation equipment and suction machines. There was no time to look for missing supplies and no one to whom we could complain. However, in the few hours before we started our drive toward Sinai, the medics and I spent time familiarising ourselves with the contents of our containers so that we would know where to find each item when we needed it. I made sure that the laryngoscopes worked properly, that we had enough batteries and that all our flashlights were usable. We reviewed the medications in the 3

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Personal view containers to ensure that we knew what was available. We augmented each medic’s backpack with extra supplies so that he could act independently if we become separated. I kept one container with us and placed the other three in separate vehicles so that if one vehicle was lost we would not lose all our supplies. To our great disappointment, we were not assigned an ambulance, but were issued a drafted civilian commercial van that we were expected to quickly retrofit with essential equipment and supplies. The military ambulance we had formerly used in our training was a Willys fourwheel drive, painted brown, and could travel in sand and other difficult terrain. It was well outfitted and contained all the medical equipment needed to care for the wounded, including oxygen and suction outlets, bright surgical lamps and four stretchers. It also had plenty of storage areas and cabinets for essential equipment and supplies. By contrast, the civilian van we received was much smaller, without four-wheel drive capability or any of the above amenities. The van had been painted blue and had no signs to distinguish it as a medical vehicle. This particularly concerned me, because such a vehicle would stand out in the desert and thus could be easily targeted by the enemy. I enquired about getting a camouflage net to cover the van but none was available. An idea occurred to me as I looked around and saw vehicles covered with dirt—why not create our own dirty vehicle? I quickly decided to change the colour of our van by improvising camouflage. We hosed the van with water and then covered it with soil. Once the mud dried, the van looked the same brownish-yellow colour of the soil and thus blended well in the terrain. I was not sure how long this ‘camouflage’ would last, but figured that, if necessary, we could repeat the ‘painting’ again. In the ensuing days, the van would become our second home. It carried all our urgent medical supplies while the rest was placed on supply and command trucks behind us. We made sure that we

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had several large drinking water containers and sufficient food ration boxes. We fitted the van to carry two stretchers and arranged it so that there were places where we could store intravenous liquid, oxygen tanks and other essential emergency equipment. Yet, despite our valiant efforts, our van was a poor substitute for a real ambulance.

EXPERIENCING THE HIGH HUMAN COST OF WAR Perhaps the gravest issue facing medical personnel is continuous exposure to the cost of war in terms of human suffering, necessarily creating a heavy emotional burden on the medical team.1 The heavy cost of this war struck me every time I cared for a mortally injured soldier. Each time, I experienced a painful sensation that I had lost someone close, like a member of my own family. I had always felt that kind of pain when I learned about the death of an Israeli soldier or an Israeli citizen, especially someone who had died prematurely. Growing up in a small country, surrounded by enemies, made me feel as though we had been weakened by the death of any one of us. Although I had previously witnessed our war casualties, especially during the Six Day War, I felt different during the Yom Kippur War, perhaps because I had become a father and now had a family of my own. Moreover, over the years, I had experienced the loss in battle of several close friends and had seen the devastating effects of their deaths on their families. I knew that fallen soldiers had families and friends who worried about them and who waited and prayed for their return. At the worst time, they did not know that their loved one was dead and were still hoping that they were safe. I shivered when I thought about the impending visit by the military authorities to the soldiers’ families and of their sorrow and pain as they would learn about the death of their family members. It dawned on me that besides the soldiers being the victims, it was also their wives, children, parents, grandparents and friends that would be forever traumatised. Their lives would be

forever changed. I had never gotten over this realisation and never will.

CONCLUSIONS Serving as a battalion physician in the Israeli Army during the 1973 Yom Kippur War, I encountered numerous challenges. My challenges were to take care of my soldiers’ medical and psychological needs and also to preserve and ensure the physical survival of my medical team. I had to deal with my own anxieties and fears and the strain of experiencing the high human cost of war. I also had to constantly assess our strategic situation; be informed of and anticipate future events; make sure that the medical team members act also as soldiers; be a role model to others; practice preventive medicine; deal with my soldier’s fear, anxiety and post-traumatic stress disorder; be always available to the soldiers; improvise when needed and respect human life—even if the life was that of our enemy. These were the issues I had to navigate as I performed my duties as a battalion physician. Competing interests None. Provenance and peer review Not commissioned; externally peer reviewed. To cite Brook I. J R Army Med Corps Published Online First: [ please include Day Month Year] doi:10.1136/ jramc-2014-000268 Received 8 March 2014 Revised 11 July 2014 Accepted 20 July 2014 J R Army Med Corps 2014;0:1–4. doi:10.1136/jramc-2014-000268

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Brook I. In the sands of Sinai: a physician’s account of the Yom Kippur War. Charleston, SC: CreateSpace Publication, 2011, ISBN-10: 1466385448. Brook I. Calm under pressure and fear under fire: personal experience of a medical officer. Mil Med 2001;166(12 Suppl):61–2. McAllister P, Hughes JH. The symptoms and recognition of post-traumatic stress reactions. J R Army Med Corps 2008;154:107–9. Hertzog C. The War of Atonement. October, 1973. Boston: Little, Brown and Company, 1975. Levy G, Goldstein L, Erez Y, et al. Physician versus paramedic in the setting of ground forces operations: are they interchangeable? Mil Med 2007;172:301–5.

Brook I. J R Army Med Corps Month 2014 Vol 0 No 0

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The experience of a battalion physician in the Yom Kippur War Itzhak Brook J R Army Med Corps published online August 28, 2014

doi: 10.1136/jramc-2014-000268

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