Triage and Terror

A doctor reports from the front lines of Bashar al-Assad's war on civilians.

NORTH SYRIA — Being an emergency room doctor gives you a strange set of priorities. We can't wait to get sucked into a crisis -- the bigger the trauma, the better. But sometimes, you get more than you bargain for.

On Aug. 27, I was sitting on the hospital balcony overlooking the olive groves in a northern Syrian hospital, drinking my fifth cup of sweet, sugary tea. Business was slow -- for the overworked Syrian doctors and nurses in this northern Syrian hospital, it must have been a blessing.

I had come to help, and was accompanied by a BBC Panorama team that was filming the work of Hand in Hand for Syria, the British charity that runs the hospital. I began to think my sole work that day would be to amuse the staff with my limited Arabic, drink tea, and show empathy to the victims. I admired the doctors for having stayed to work, when so many others had left the country. Medical workers are prime targets for Bashar al-Assad's regime and some have been detained, tortured, or disappeared for treating the war-wounded rebel fighters.

The sudden screech of a truck pulling into the hospital courtyard was the only alert we received that a patient had arrived. Back home in my London hospital, a red phone alerts us with a loud, distinctive ring that a seriously injured patient is en route. Here in Syria, there's no such luxury.

I ran down the stairs to the emergency room -- a sparse room with two trolleys, one monitor that measures blood pressure and oxygen levels (the only one in the whole hospital), and oxygen capability for only two patients at a time. Hand in Hand for Syria has turned this former clinic into a functioning hospital -- but despite ongoing donations, it is still under-resourced and staff are working around the clock. The gap between Syrians' needs and the available resources is simply too great.

An eight-month-old baby lay on one of the trolleys, crying in pain. He had a reddened face, and some minor evidence of early blistering on his forehead. The skin had slightly peeled on his right foot, and his left leg was red and hot to touch. It looked like he had been scalded. The initial explanation of what had caused the injuries was confusing -- I heard something about a car crash.

As I worked, a young boy appeared by my side. He was covered in white ash from head to foot,  looking almost ghostly. His eyes were wide and staring -- he moved slowly and quietly. On the right side of his head, he had a large full-thickness laceration -- the medical term for when a cut has gone through all the layers of skin. The flap of skin folded out to reveal his skull. "Where shall I go, my sister?" he asked. This car crash must have been a huge pile up, I thought.

Worried he would collapse, I held him upright and looked for a trolley or chair. As I turned the corner of the emergency room, I saw this was no car crash -- this was war. Within ten minutes, the hospital was overflowing with casualties. The patients packed the tiny hospital, laying on the floor or propping themselves up against the wall in the reception area, writhing in pain.

These were the victims, I would soon learn, of an incendiary attack by a Syrian regime warplane on a school playground in the city of Aleppo. The jet passed overhead several times, and then dropped a napalm-like substance on the area, killing at least 10 people and injuring many more. Of those who survived, many had burns over 50 percent of their bodies.

The attack came amid an international debate over how to respond to an Aug. 21 chemical weapons attack in the eastern Damascus suburbs, which the United States, Britain, and France all say was perpetrated by the Syrian regime. As the U.S. Congress prepares to debate whether the horrors of that attack demand American military intervention, however, the massacres that Assad routinely perpetrates through other means risk being forgotten. As doctors, we are keen to find a way to secure a humanitarian corridor that allows healthcare workers and NGOs to work safely -- without risking becoming targets themselves.  While chemical weapons are undoubtedly horrific, the vast majority of deaths in this conflict have been caused by conventional weaponry -- and neither an American military strike nor any other action appears poised to end that tragedy.

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In the crowded emergency room, I was coming to grips with the enormity of the crisis. It was like a scene from a horror movie: Syrians streamed into the hospital, walking with outstretched arms to keep their burnt limbs away from their bodies, swaying side to side, their clothes shredded or gone. In the chaos and noise, I thought the hospital itself was under attack -- not such an unlikely prospect, as hospitals have previously been hit in this conflict.

"This is not the first or the worst scenario, and probably it won't be the last," one Syrian doctor told me. "But maybe this time someone will listen, because the camera is here. They don't listen when we tell them."

Ahmed, a 15-year-old boy, sat shivering and quiet on a chair. He was naked apart from his underpants. I looked at his hands -- the skin was falling off like he had been peeled.

"Assad, look what you have done," a woman screamed. "Why can't you die, Assad!"

The woman's husband was by her side. "Look what he did to her," he sobbed. She had suffered burns to her face -- the pain must have been horrific.

The staff tried to restore order to the chaotic emergency room. I couldn't recognize my colleagues -- their faces were obscured by white masks, as they initially believed that they were aiding the victims of a chemical weapons attack. Panic filled the air. I wasn't wearing a mask. I carried on in autopilot, unmasked, until a nurse forced one onto my face.

We ripped open bags of fluid to pour over patients, applied burn cream to their wounds, and moved the victims into wards. I treated five teenage boys: One of them, Mohammed, was so badly burned that his hair had melted. His body still emanated heat. "I want to sleep," he kept saying. I learned later that two of the boys I treated died of their wounds in Turkey.

If any one of these patients arrived to our London hospital, they would have instantly been transferred to a specialized unit to care for their burns. But here, with 28 victims and only basic care to offer, I felt so useless. The best we could do was move the patients around to ensure they had IV lines for fluids, and give them painkillers and antibiotics.

One girl spoke to me in English. Her mother cried by her side. "How bad is my face, my sister?" she asked, composed and calm despite obviously being in terrible pain. "Do you think they can fix my face?"

The girl and her fellow students had been attending class in a quiet, relatively affluent Aleppo neighborhood when the attack started. The headmaster of the school, Mohammed Abu Omar, described fire falling like rain, burning whatever it touched. He put out the flames on the students' bodies with his hands, sustaining minor burns in the process.

The first bomb hit a four-story building, penetrating three floors and injuring my first patient -- the baby. Everyone ran out of the school to help the injured, according to one of the unharmed students. His quick-thinking teacher saved him by grabbing him and throwing him into a ditch. The second bomb hit the school courtyard, right outside one of the classrooms.

The bombs incinerated everything around. Three students were killed instantly. Their charred, unrecognizable bodies were brought to us in the hospital. I was told they were girls, but I would never have known.

The attack reduced humans to strange mannequin-like beings, with hardened skin -- impenetrable to our efforts to place IV lines into those still alive. One boy's body had been fixed in position; he was unable to move his arms, legs, or even face. Only his eyes were moving, registering that he was alive and terrified. Doctors sedated him and placed a tube down his throat so he could breath. I could not find a single patch of unburned skin to place an IV line.

I later learned that the boy died on the way to the Turkish border. He was laid to rest without anyone knowing his name -- his family was unknown, possibly refugees in Turkey. I have a strong desire to see a photo of him from before the attack -- to know who he was. To see his face before it was so hideously disfigured.

I visited the bomb site a couple of days after the attack. The same strange odor that I had smelled at the hospital -- a strong, sickening scent mingled with the smell of burning flesh -- hung over the ruined school. A student's charred notebook lay at the bottom of the crater left by the bomb, the writing still visible. But the author of those scribbled pages was dead.

Somehow, the attack has not broken the spirit of the Syrians living in the neighborhood. As we walked around the school, a young girl, just eight years old, ran out to see us. Her hair was cut into a rough bob, hanging above her shoulders. She brought us a bottle of water from her home. She told us that her long hair had been cut short because it had caught fire that day. Never mind, we told her -- it will grow back.



The End of Pax Netanyahu

With the war on its doorstep, how long can Israel manage to stay out of Syria?

TEL AVIV, Israel — Israel has been watching the approaching U.S. attack against Syria from the sidelines. It is, of course, rooting for an American success, but also -- perhaps like the United States itself -- remains doubtful about the ramifications even of a successful military strike. The Israeli leadership has no illusions about the nature of the Syrian tyrant's possible successors: The view from Jerusalem is that replacing a mass murderer with al Qaeda-linked Islamists is no victory at all.

Israel has so far been able to largely insulate itself from the upheaval of the Arab Spring, but the American strike may be a sign that this era is coming to an end. While the last three years have been the calmest period for the average Israeli citizen in more than a decade, there are signs that the Israeli military is finding it harder and harder to remain aloof from the regional upheaval.

Pax Netanyahu is all but over. According to sources within U.S. President Barack Obama's administration, Israeli warplanes have struck targets in Syria at least four times since the beginning of the year. Katyusha rockets were recently launched from Lebanon at northern Israel, which caused the Israel Defense Forces (IDF) to strike Lebanon in return. Meanwhile, rockets from the Sinai Peninsula targeted the southern Israeli city of Eilat, causing the IDF to bomb a group of Islamist terrorists in the region. It was the first time Israel had assaulted Egyptian territory since the Egypt-Israel peace agreement in 1979.

Israeli defense officials are keeping in close contact with their U.S. counterparts on Syria; a high-level Israeli delegation visited Washington just this week to game out the allies' response. The Israelis assume they will receive an early warning from the Americans, at least a few hours before the strike.

Israeli defense officials have told me that their understanding of U.S. plans largely agrees with the information published in the media in the last few days. The assault, they say, will be a quick operation: A sophisticated strike, employing cruise missiles and probably also warplanes, will hit a few dozen targets simultaneously in the course of 24 to 48 hours. They will aim to destroy Syrian military bases, missile batteries, perhaps even stockpiles of chemical weapons -- if the Americans can be sure that the collateral damage will be minor.

Obama has said that the American intervention does not aim at toppling the Syrian regime -- and the Israelis believe him. At most, Israeli government officials expect the U.S. strike to weaken Syrian President Bashar al-Assad's position in the civil war and deter him from using weapons of mass destruction in the near future.

But the run-up to the U.S. strike in Syria has also revealed the vast differences in style between the Israelis and Americans in war-making. Unlike the Obama administration, the Israeli leadership does not spend time trying to build international support for its strikes beforehand. The Israelis hardly discuss what has already happened, much less what might evolve in the future. As in every good Jewish family, if something is not discussed, it probably never happened. The Americans -- as shown by Secretary of State John Kerry's two impassioned speeches on the topic and the public release of U.S. intelligence meant to prove that the Syrian regime was behind the attack -- do things differently.

Israel is perhaps more concerned about Washington maintaining its credibility in the Middle East than it is about achieving a specific strategic objective in Syria. Jerusalem worries about American weakness in the region: Top officials are convinced that the taboo against the use of chemical weapons should be reinforced and that Iran could perceive the U.S. failure to act as a green light to develop its own weapons of mass destruction.

As the Syrian crisis drags on -- and with the U.S. strike offering little hope or aim of conclusively ending it -- Israel looks poised to maintain its policy of containment. Jerusalem's limited aims in the conflict include preventing sophisticated weaponry from falling into the hands of terrorist groups: The IDF's four alleged airstrikes took place when Israel was concerned about immediate Syrian attempts to smuggle surface-to-surface, anti-ship, and anti-aircraft missiles to Hezbollah forces in Lebanon. Assad has threatened retaliation for these strikes, but so far has not acted. The next Israeli strike, however, could always be one too many for the Syrians.

Prime Minister Benjamin Netanyahu's intelligence advisors tell him that there is only a low probability that the Syrian regime would respond to an American strike by hitting back at Israel. All the evidence suggests Assad would rather contain the attack and concentrate on fighting the Syrian rebels -- not pick a fight with America or Israel. But the Israeli prime minister is also acutely aware, like most Israelis, that exactly the same term -- low probability -- was used by IDF intelligence almost 40 years ago in the days before the joint Syrian and Egyptian attack that started the October 1973 Yom Kippur War. This explains the prime minister's constant threats to Assad -- he wants to make sure that the Syrian president had absorbed the message from Jerusalem.

Israel does not believe it has a role in responding directly to the use of chemical weapons against any of the warring parties in Syria, though it has been monitoring these incidents closely. In April, when an IDF intelligence officer publicly announced that Assad had used chemical weapons in at least two incidents, he was quickly rebuked by the Obama administration. It took the Americans two weeks to grudgingly admit that the Israelis were right about what had happened.

Like the United States, Israel has no good options in Syria. Netanyahu realizes that Assad's survival at this stage would represent a huge achievement for the Iran-Hezbollah axis, which represents Israel's main antagonist in the Middle East. On the other hand, the prime minister worries about al Qaeda's growing presence: A senior IDF official recently told me there were about 10,000 jihadi fighters in the southeastern Golan Heights, just across the border from Israel. At some point, Israeli officials know, these zealots will show an interest in their Jewish neighbors.

Although Israel had never announced this publicly, it secretly wishes success for both sides in the Syrian civil war. Those YouTube videos showing endless rows of Syrian corpses are indeed terrible -- but they do not change the basic Israeli belief that nothing good will come out of a victory for either side.

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