Imagine your world as you know it is crumbling down in front of your very own eyes. Your home, your school, your place of worship, your friends, your family, and even you. You’re one of the few healthcare professionals that are scrambling to save thousands lives and preserve your people as long as possible, but severely injured patients keep piling in and you feel helpless. You feel helpless, and even the tool that you usually rely on to guide you through such difficult mass casualty situations is making you uneasy. As a doctor tasked to prioritize patients’ care based on severity of injuries, you have an established triage system that is commonly used, but with this comes conflicted emotions and the complexities associated with principlism.
Triaging During Trauma
Triaging, of course, is an integral part of doctors’ course of action which simplifies the process of deciding which patients should be prioritized, how to ration medicines, and best courses of action which all allow for healthcare providers to disregard their own emotions and not allow them to interfere with their delivery of care. Triage is the act of prioritizing patients based on the degree of injury and urgency of need for care. There are various models that are used including Simple Triage and Rapid Treatment (START) primarily used in the United States, which consider the patient’s pulse and pulse rate, capillary refill time, presence of bleeding, and ability to follow commands [1]. A similar model—Jump-START—is used for those under the age of 8 and acknowledges the difficulty for children to follow commands and their increased risk of respiratory failure as they are not yet fully developed.
However, in times of disaster and mass casualty, physicians turn to secondary triage systems to further differentiate the prioritization of patients. The four main pillars of medical ethics or bioethics are 1) respect for autonomy, 2) nonmaleficence, 3) beneficence, and 4) justice, which also encompasses informed consent and patient autonomy [2].
The numerous models of triaging used around the world are important to protect the quality or scope of care in non-disaster situations, but there are often plentiful resources to adequately treat all compared to mass casualty situations. Contrastingly, in emergency situations, where death tolls and injured counts are significantly higher and resources limited, triage models used specifically for emergency situations are arguably more important in ensuring distributive justice [3]. This is partly due to the fact that the nature of mass casualties makes it more difficult for healthcare providers to prioritize patients when the amount of critical injuries that need immediate care overwhelm resources. It also becomes much more difficult to locate family members efficiently in such emergency situations, and therefore physicians must proceed with emergency procedures without surrogate consent.
In hopes to bridge this gap, secondary triage is a mode of triage utilized during emergency situations. When limited pre-hospital care is provided due to 1) limited resources on site, 2) the large influx of injured patients, and 3) a large amount of time passing during transportation, secondary triage is performed immediately performed by a doctor or surgeon instead of a triage nurse to minimize time between admission and treatment/stabilization. This comes after the primary triage usually conducted on scene by EMS providers. Though this system of triage undoubtedly decreases the time until treatment, it complicates the ability of healthcare providers, specifically physicians, to dutifully uphold the pillars of principlism in emergency situations by simultaneously assessing and treating patients as their medical judgment might sometimes be clouded by personal ethical dilemmas and concerns.
Palestine’s Point of View
In the case of Israel and Palestine, though tensions have been bubbling between the two nations for decades, the eruption of war on Oct. 7 understandably pushed the healthcare systems—particularly that of Palestine—over the edge. With only 13 hospitals operating at a low capacity, this conflict has only exacerbated the already stressed hospital system, with the patient-to-bed ratio only increasing [4].
As of Jan. 30, 26,901 fatalities have occurred in the Gaza Strip due to the conflict, with 70% of those being women and children, and 7,780 individuals remain unaccounted for or beneath the rubble [5]. The effects are far more wide-ranging, with 65,949 injured and 1.7 million displaced, equating to 75% of the Gaza Strip’s population.
In terms of balancing increased patient flow, it is unclear which specific method of triage is being used in the current conflict in Gaza. In previous conflicts in Gaza, Trauma Stabilization Point (TSP) has been implemented in partnership with the World Health Organization (WHO).This included the formation of hospital-like establishments housing specialized forces of emergency responders equipped to respond to minor and non-trauma emergencies, provide first aid, and triage patients on scene [6]. “Critical zones” were established throughout Palestine in areas where a high number of patients were injured; these TSPs served to decrease the load placed on overflowing hospitals and their staff, allowing hospitals to treat more critical patients that required surgery and other intervention. Depending on the stability of patients, some were transported to nearby hospitals after being stabilized through first aid and care for non-trauma emergencies.
Currently, numerous volunteer teams including emergency medical technicians, physicians, and surgeons from around the world have contributed to caring for the injured in Gaza. Some first responders provide care at all of the three field hospitals in the Strip which are “fully functional” and likely allow for lightened patient loads and strains on hospitals. Yet, attacks have also targeted health facilities and ambulances, further compromising healthcare providers’ ability to provide care; 95 health facilities have been affected, with 27 hospitals damaged and 86 ambulances affected.
As of the week of Jan. 30, none of Gaza’s 36 hospitals are fully functional. Only 13 are open, but are providing “severely limited” services and running at 200% capacity, according to the WHO and NBC [7]. James Smith, a volunteer emergency medical technician with the International Rescue Committee working at Al-Aqsa hospital in the heart of Gaza emphasized the overrun system. “Nurses this morning said they had 500 injured overnight. Three people died in resus this afternoon,” Smith said, referring to resuscitation. “The system has fallen apart,” he said in a statement to NBC on Jan. 4. “Not even the best triage system can withstand this.”
Doctors and other providers have been forced to treat patients without access to analgesics, antibiotics and anesthesia, compromising quality of care and complicating otherwise routine and painless procedures. The combination of limited resources and space to treat patients has left patients lining the floors of hospitals, and without analgesics, “simple injuries” can quickly progress, contributing to infections and more serious medical problems, sometimes necessitating amputation. Additionally, communicable diseases have been reported to increase 23-fold since 2022, exacerbating the spread of disease.
Sacrifices of Healthcare Workers
In this time of crisis, all healthcare provider duties from trauma surgeons and critical care nurses to emergency medical technicians and emergency medicine physicians have been bombarded with an increased patient load. As expected, the overwhelming number of hospitals, along with the heightened state of emotions that many healthcare workers are experiencing as a result of sacrificing their time with their family, putting their lives in danger’s way, and navigating the gray lines surrounding patient care during a war, has had a detrimental impact.
Dr. Mohammed Harara, a 27-year-old doctor in his first year of practice is one of the five remaining doctors at Nasser Hospital—one of the 13 remaining partially functioning hospitals in the Gaza strip—and cares for 850 patients who call the hospital home [8]. Despite this, they still lack basic medical resources like anesthesia, beds, and gloves, with patients being treated in the hallways. Hamara, who used to work at Al-Shifa Hospital which was shut down due to IDF surrounding and attacking the facility, now lives in a tent outside Nasser Hospital, and has trouble finding his own time without reliving the day’s events. “Every night, after a hard [day of] work, I can’t sleep due to what I saw during the day—the vision of martyrs and injury,” Hamara told NBC News. According to Doctors Without Borders, Nasser Hospital is also “nearing collapse.”
In addition, Harara is unable to reach his family and is not sure of their whereabouts or safety. Putting aside his dream of becoming a plastic surgeon, Harara has continued to serve his people during this time of crisis, sacrificing his mental health, but he emphasizes that someone needs to provide care for citizens. “Many question [why I don’t] leave the hospital right now... [but] who will receive the injuries and who will cure them?” Harara said.
Informed Consent
Along with challenges surrounding lack of resources and a seemingly never-ending patient load, informed consent has become particularly relevant in the treatment of pediatric patients. Since 70% of Palestinians killed are women and children, the need for emergent pediatric treatment is high. Yet, with countless families being separated due to the attacks, both physically in the rubble and due to parents facing their own injuries, fewer mothers and fathers are present for their children’s treatment. Hence, informed consent is difficult to institute during a disaster due especially with pediatric patients due to the a) lack of mental clarity and trauma of parents of children associated with the event, b) limited time available to perform life-saving and life-sustaining treatment, and c) separation of families—but patients must be treated to survive.
Similarly, due to the mechanisms of strikes and other attacks utilized by Palestinians and Israeli forces, it is often difficult to keep parents and children together due to injuries with children oftentimes being separated to shelter locations for safety. This complicates the informed consent process and makes it exponentially more difficult to communicate treatments being performed to patients and their families. Moreover, the severity of injuries that comes from war and similar disasters limits the time a physician can spend on one patient, and along with limited pre-hospital care increases the need for immediate, life-saving treatment. When parents are either unable to comprehend treatments and provide consent for their children or themselves, treatment is thankfully not delayed.
According to the American Academy of Emergency Medicine, emergency room doctors should always obtain informed consent before performing “non-routine procedures or treatments unless emergency conditions exist where delay would cause harm.” This is one of the criteria that principlism outlays as a reasonable exception, where informed consent can be compromised to ensure optimal patient outcomes. This also holds true in Israel and Palestine, with the International Code of Medical Ethics of the World Medical Association stating that during emergencies when patients are not able to contribute to their care and no representatives are available, the doctor may “initiate an intervention without prior informed consent in the best interests of the patient and with respect for the patient’s preferences.” The code also acknowledges that when patients have “substantially limited, underdeveloped, impaired, or fluctuating decision-making capacity,” the doctor must reasonably make choices for the patient and carry out the patient's preferences, if known. Though these exceptions exist, the gray area of this code can leave healthcare providers uneasy at the accurate course of action as they struggle to balance informed consent and optimal patient care which overall complicates emergency care and the process of triage. This can also lead to providers unknowingly compromising care in non-disaster situations by not upholding informed consent out of habit or accessibility.
It is unclear to what extent the principles of informed consent and autonomy can be maintained during this war, but it remains an integral part of medical treatment during disasters, and patient and family wishes are honored when applicable.
Patient Privacy
In addition to the increased difficulty of treating patients in accordance with informed consent, a lack of confidentiality and patient privacy also arises due to this mass casualty situation. Because hospitals are overwhelmed and have limited resources, patients in both Israel and Palestine are being treated on the floors of hospitals. Though the severity and urgency of the situation somewhat warrants this, it does not supersede the vital concept of patient privacy that doctors and healthcare professionals strive to uphold. Furthermore, the understaffing and lack of available resources are evident with only three hospitals in the Gaza Strip providing “basic first aid care” and 15 providing “partial services” [9].
Insufficient Resources, Compromisation of Care
Healthcare professionals are currently overwhelmed by the influx of patients and constant calls to provide care. In Gaza, Doctors Without Borders emphasizes how medical teams are “exhausted,” often working around the clock to treat all patients [10].
According to Doctors Without Borders, or Médecins Sans Frontières (MSF), Al-Aqsa Hospital and Nasser Hospital are the main hospitals that are “overwhelmed” [11]. MSF Team Leader Katrien Claeys notes the spread and progression of disease that the team and other Palestinian healthcare workers encounter. "We see patients with signs of infection and necrotic tissue, as they have not received a change of wound dressing in days and sometimes weeks," she said in a press release on Dec. 4.
Another issue that is evident in Gaza since the inception of the war is the lack of resources and staffing available to treat those with chronic conditions and existing health conditions or routine treatment and monitoring because of the influx of emergency patients. Similar situations are observed in pandemics like that of COVID-19, where hospitals were overwhelmed, understaffed, and under-resourced [12]. In Gaza, this is exacerbated by the already insufficient resources available to treat patients because of the Israeli blockade of electricity, water, and aid to the Gaza strip [13].
Overall, the war has significantly decreased resources available to Palestinian doctors and in turn, complicated ethical triaging and treatment due to the increased difficulty to provide and acknowledge patient autonomy, informed consent, confidentiality as well as navigate compromised care. Doctors and healthcare professionals are working around the clock in both Israel and Palestine to provide care for patients, but the emotional and physical toll is bound to manifest eventually as hospitals become even more overwhelmed by the disaster. Nevertheless, healthcare professionals continue to uphold their duty of serving the people amidst the challenging ethical circumstances.
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4. Mahmoud, Abuzerr, H., Samer. (2023, December 1). State of the health-care system in Gaza during the Israel–Hamas war. Health-care system in Gaza during the Israel–Hamas war. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(23)02634-X/fulltext.
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8. NBC News. (2024, February 12). 27-year-old doctor cares for 850 patients in Gaza’s Nasser Hospital. YouTube. https://www.youtube.com/watch?v=jvdkMitUl1M.
9. Haddad, M. (2023, November 20). World Children’s Day tragedy: Gaza’s 5,500 lives lost to Israel’s attacks. Al Jazeera. https://www.aljazeera.com/news/2023/11/20/world-childrens-day-tragedy-gazas-5500-lives-lost-to-israels-attacks#:~:text=Since%20October%207%2C%20Israeli%20attacks,most%20of%20them%20presumed%20dead.
10. Kekatos, M. (2023, December 5). Hospitals in southern Gaza are at “breaking point,” international organizations say. ABC News. https://abcnews.go.com/International/hospitals-southern-gaza-breaking-point-international-organizations/story?id=105382793.
11. Gaza: “The situation is catastrophic; the hospitals are overwhelmed.” (n.d.). Doctors Without Borders - USA. https://www.doctorswithoutborders.org/latest/gaza-situation-catastrophic-hospitals-are-overwhelmed#:~:text=The%20hospitals%20are%20overwhelmed.,The%20bombardments%20are%20very%20intense.
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13. Yerushalmy, J. (2023, October 17). Crisis in Gaza: Why food, water and power are running out. The Guardian. https://www.theguardian.com/world/2023/oct/17/crisis-gaza-why-food-water-power-running-out.