July 25, 2006: My daughter, a pediatric resident at Haifa's Rambam Medical Center, finishes her 24-hour shift and looks forward to a long sleep prior to celebrating her birthday. She emerges from the hospital into the light of day to find police holding back curious bystanders from a cordoned- off traffic circle, a few meters from the hospital entrance. “A Katyusha had landed nose-down in the center of the traffic circle,” she recalls. “It made the war very real and close for me.” For 34 days during the Second Lebanon War, more than 60 rockets landed within a kilometer radius of the hospital. Debbie Hemstreet, who works as an English editor and writer for Rambam Medical Center management, recounts, “Doctors had to take care of patients under fire. Because we did not have a shelter, we had to care for patients in the basement! But the hospital had to keep functioning.” Rambam is the regional health center of the North and is a Level 1 trauma provider; it is also the referral center for 12 district hospitals as well as serving the IDF Northern Command, all UN forces stationed in the region and the US Sixth Fleet. During the 2006 war, almost 800 casualties were admitted, among whom were more than twice as many civilians as soldiers. The hospital's vulnerability to attack prompted the administration to seek solutions that would assure the safety and security of patients and personnel, and accommodate an increase in the number of patients in any future conflict. Explains Hemstreet, “First of all, the emergency department was fortified against missiles. Outside the building, an area was prepared which can be sealed off to decontaminate victims of a chemical attack.” Following the completion of the ER in 2009, plans went ahead for an underground parking lot that would convert to a hospital in times of emergency. Initially, it was planned that the hospital would accommodate 750 beds but, as a regional hospital that might need to absorb hundreds of patients from other hospitals in the North, the Health Ministry insisted on a 2,000-bed facility. March 25, 2014: Rambam Medical Center holds a major drill to test the hospital's operational preparedness. The drill simulates Rambam under missile attack and involves the evacuation of patients, beds and equipment to designated locations on each of the floors of the underground hospital, including complex intensive care, dialysis and surgical equipment. The drill also addresses logistics, including operating the ventilation system and electronics, setting up toilets and showers, and the removal of all vehicles from the parking lot. Nothing differentiates this park-ing lot from others of its ilk – that is, a safe place to leave your car while you go about your business. I drive around searching for the elusive empty space, over floors that literally squeak with cleanliness. “The floors squeak like that because they're covered in an epoxy paint that keeps the floors easy to clean and maintain,” explains Kobi Bossel, a civil engineer and the project manager of the integrated parking lot/ hospital. THE PARKING lot accommodates up to 1,500 cars in peacetime and can be transformed into a fully functioning hospital within 72 hours in the event of war. There are three levels, penetrating 16.5 meters underground, each level measuring approximately 20,000 square meters. When in hospital mode, the area has a maximum capacity of 8,000 people, including up to 2,000 patients and 6,000 doctors, nurses, maintenance and other staff. There is also a day care center for the children of hospital personnel. It is the largest underground, fortified emergency hospital in the world. Bossel, who began working on the project in 2007, describes how in the event of an attack, Minus-3 is the safest level to be on. “Minus-3 is fully protected from chemical attacks and is also fortified against missiles,” he explains. “If there is a chemical attack, the filters can be quickly replaced. Up to eight surgical operations can be performed simultaneously on this level.” Bossel continues, “In Minus-2, 60 percent of the area of is fully protected from chemical attack and is 100% protected against missiles. If there is a chemical attack, you need to put on a gas mask before going into an unprotected area through designated sections, which allow you to move from the chemically clean area to the chemically affected area.” Minus-1 is not protected from chemical attack and is only partially protected from missiles. Unprotected areas are marked on the floor. This level also contains showers to decontaminate people who might have been exposed to chemicals, and post-trauma, emergency and logistics sections. Access to the lower floors is via sheltered ramps or one of 11 staircases. In the event of war in the North, Rambam Medical Center will switch to emergency mode and the parking lot will begin its transformation into a hospital. Says Hemstreet, “When an emergency is declared, car owners respond to loudspeakers telling them to remove their cars; if the owner doesn't show up, the car is towed. The area is then cleaned and we begin to move the patients down, starting with triage and decontamination if necessary, to the different units on the lower levels as they become operational. Bedridden patients are moved directly from the basement of the hospital to Minus-1 of the parking lot, through a corridor wide enough to accommodate a hospital bed.” Where there were six cars, there are now 10 beds. The whole area is sealed and on Minus- 2 and Minus-3, some 400 valves are switched to permit the flow of treated air. Logistical equipment is brought in, including toilets and showers, air-conditioning sleeves and medical equipment. Says Bossel. “There is a container in place with 24 tons of medical supplies, which can then be transferred to each floor as required. We also have an internal communication system which is deployed only during wartime for communication among the medical staff.” The transformation from parking lot to hospital is completed within 72 hours. The hospital can function for another 72 hours without the need to augment supplies, such as food. If there are power cuts and the hospital is required to use the generator for electricity, there's enough fuel to last three days. There's also a reservoir of water, which must be refilled after 72 hours. MOST BUILDINGS in the Rambam complex are interconnected, allowing access to the underground hospital in an emergency. The Rappaport Children's Hospital is located directly above the parking lot, enabling an elevator from the building to go directly to Minus-2 and Minus-3. For children too weak to be moved, the lower three floors of the children's hospital are fortified. Future projects include fortifying buildings that house patients too incapacitated to be moved, such as those in cardiology and oncology. There are also plans to build a biomedical discovery tower that would combine research between Rambam doctors, the Technion-Israel Institute of Technology and other institutions. The massive investment in the Rambam emergency hospital in terms of money (the project cost somewhere in the region of NIS 500 million), ingenuity and care for the welfare of Israel's citizens is impressive, moving even. But I share with Hemstreet her most fervent hope: that the parking lot will remain forever a parking lot, and that its metamorphosis into a hospital will never need to be implemented.
