Here’s a riddle: What do the Ebola virus, a flight attendant, a military flyover, a tourist in Denver and someone in cardiac arrest over the Atlantic have in common? Answer: “Aviation Medicine.” It’s a medical field that very few have heard of, but Dr. Yehezkel Caine has been
involved with it for close to 50 years. The British-born doctor, now president of Jerusalem’s Herzog Medical Center, was already a qualified physician when he joined Israel’s Air Force, training as a pilot. “Naturally,” he says, “the two melded together.” By the end of his Air Force career, he had become its chief medical officer. Caine was in Denver last May for the annual meeting of the Aerospace Medical Assn. and the Undersea and Hyperbaric Medical Society.

He sat for an interview with the IJN about the multifaceted and highly specialized field of aviation medicine, and shared the work of the Herzog Medical Center, the oldest, continuously operating hospital in Israel.

I. AVIATION MEDICINE

QUESTION: What is aviation medicine?

Dr. Caine: Aviation medicine deals with the effect of atmospheric flight on the human body. For people who live at sea level, coming to Denver is a barometric change, which give some people headaches, sleepiness or exhaustion. It takes time to become acclimated to the altitude change. We see that in Jerusalem, and Jerusalem is not as high, about 2,800 feet.

The Herzog Medical Center itself is at 720 meters (2,362 ft.). I know that precisely from landing helicopters there.

THE EFFECTS OF FLYING

The effects of flight on the human body apply first and foremost to pilots and air crew, anybody manning the aircraft.

That includes cabin crew if you’re talking about passenger aircraft, but it also applies to passengers. Everybody flies. Four billion people fly every year. That’s a lot of people leaving the confines of the Earth. Most passengers fly very successfully with very few problems.

But not everybody is fine. Things happen to people if they go to the supermarket, but it’s totally different if it happens in an airplane at 35,000 feet within a closed tube and a lot of panicking by people in the seats around you.

Sometimes a passenger can become very sick. Today, most airlines have air-to-ground communication with a fixed medical advisory location. So you can actually transmit, say, an ECG or clinical details to a central place. There are three or four of these commercial companies that supply services to the airlines. The air crew can actually consult a medically qualified individual using the kits supplied to the airplane.

If you’re lucky, you’ve got a doctor on board or a paramedic, who just happens to be a passenger.

It’s happened to me quite a few times. In most cases, not all, things work out OK.

Occasionally, you have to make an emergency landing, because if you’ve got another six hours of flying time and a person’s had a heart attack, you’re going to land at the closest spot where he can receive proper treatment.

QUESTION: Is everyone fit to fly?

Dr. Caine: We have clinics that evaluate patients for flying. Just recently I had a patient, an elderly gentleman, who was in his 80s, had lung disease and very much wanted to visit the States. His grandchild was getting married. His personal physician, said, it might not be advisable. You’d better go and have a consultation. The biggest issue with medication is the shifting clock. Take a man who is taking heart medication three times a day. If he leaves from Denver, change planes in New York, and carries on to Israel, he’s shifted nine hours in a period of 18 to 20 hours. What happens with his medication? We can help people in how to handle that sort of a problem. Sometimes you actually need to change the medication.

THE FLIGHT CREW

Most of our work deals with the health of the aircrew. Think of how many hours they spend flying. They are at risk for sleep deprivation, jet lag. They may carry a disease or become infected by passengers. There are injuries. Two types of injuries are very common. One is that the cabin crew gets run over by their food carts. That can happen in sudden turbulence. The other is when they open the overhead bins and objects fall onto the passengers or the cabin crew.

Every pilot, from the most basic civilian student pilot all the way up to the captain of a jumbo jet, all have to have current medical certification.

You’ve got hundreds of thousands of private pilots flying. Somebody has to keep an eye that they’re not flying when they’re blind, deaf or unfit to fly for other reasons. There is a whole process, “aeromedical qualification licensing.”

AEROMEDICAL QUALIFICATION LICENSING

The rigor of the certification varies according to the responsibility. This is closely controlled by both national regulation in every country and international standards.

Every country adheres to at least the minimum international standards, but most countries also have a subset adapted to their own needs. To perform an examination on a pilot or a cabin crew member, you have to be licensed for it. The regulatory body of the country (in the case of the United States, the FAA) issues a certificate called an “aeromedical examiner” (AME).

Pilots are required not only to go for their annual checkup — and in some cases its a twice yearly checkup. Commercial pilots are required to undergo medical examination twice a year.

If they have any medical problems, they may have to requalify their medical certificate — if they’ve gone through surgery, or had a severe disease or whatever. Has it affected their ability to fly? The whole idea is safety.

Air travel is the safest form of travel. Does that mean aircrew never have medical issues that could impact the safety of a flight? Air crew are all humans and can have various medical problems.

They’re also human in the sense that some of them try to get around the rules. It’s like somebody trying to drive when he’s really not quite qualified medically. Medically, driving is self declaratory, except for the eye test. You declare that you’re healthy, and it’s only above a certain age — in Israel it’s either 70 or 75 — where a doctor has to sign off — and the eye test every five years. That’s about it.

You can’t do that with a pilot. In civil aviation, all major passenger aircraft above a certain size have two pilots. One of the jobs is to keep an eye on your peer. It happens a few times a year that a pilot will come forward and say, ‘I’m not flying with that guy, he’s inebriated, or he’s on drugs, or something’s wrong with him.’ It requires a very mature pilot to come and say that about somebody who may be your friend, a colleague. But it’s a safety issue. I think everybody’s heard of the famous German Wings case in 2015, when a passenger flight was deliberately crashed by its pilot and everyone on board was killed. Those are extremely rare.

AIRCREW’S MENTAL HEALTH

Another topic is new criteria for mental health diagnoses in aircrew. You don’t want to disqualify somebody just because he had a bad day or an argument with his wife. There’s a very fine line, and it’s very difficult to define it.

Statistics show that we do a pretty good job. Unfortunately, every so often, like German Wings or one or two other cases, the health issue is not found in advance. Why? For mental health especially, if the aircrew doesn’t declare that he has a problem, if he’s not being treated actively by a psychiatrist who knows that he’s a pilot, there are two issues:

• An individual can walk into a psychiatrist and the psychiatrist will ask him what he does, and he’ll say, I’m a bricklayer, I’m a student, I’m a layabout. The psychiatrist doesn’t need to verify anything. He will give him medication, will treat him, will send him to psychotherapy. The guy walks out carrying a bag full of psychiatric medication, gets on the airplane and flies it. Because nobody knows what he does.

• You have to disclose whatever medications you’re on, but if you don’t, nobody will know because of medical privacy. But these things are so incredibly rare when you think of the amount of flying that goes on. The safest place is in the air. And I say that as a pilot.

QUESTION: Tell us about medical issues in military aviation. Dr. Caine: Most of my career was spent doing research and dealing with aviation problems in military operation, either in combat or preparing for combat.

Military flying is much, much more arduous and strenuous than civilian flying. Most military fighter aircraft have either one or two crew. That was brought to the forefront with the Israeli and American attacks on Iran. You’re flying a single-seat fighter from Israel all the way out to Iran, and then all the way back. In the middle you’re busy dealing with combat. What does that do to your physiology, sleep, going to the bathroom, food? These are all issues that you have to deal with.

When you’re doing three or four flights like that a day, the exhaustion, the alertness, how do you handle that? If you’re a naval pilot, not only do you have to get back and land, you have to find your ship, and you have to land on an aircraft carrier, which is like landing on a stamp in the middle of an ocean.

If it’s Israel, you’ve got to find that small country called Israel, you’ve got to find your airbase, and then go ahead and land. That’s after flying a round trip of maybe six, eight hours alone in the cockpit or with the navigator. How do you handle these things? Preparation, deciding how to handle all of these issues, the type of equipment — all these are topics that we deal with in aviation medicine.

INFECTIOUS DISEASES

Not to mention things like infectious disease, which is very topical with the Ebola outbreak in Africa. You can see very clearly how disease spreads based on air travel. This was studied very closely with COVID. Sometimes you can go back to the original person who became infected and then flew from point A to point B, 1,000, 2,000, 5,000 miles away, and you see an outbreak of that very same disease.

It happened before COVID, with MERS. The most recent outbreaks spread by air travel have been measles, because so many people today have not been vaccinated.

Two decades ago, everyone was vaccinated in childhood. But with the advent of [vaccine] denial, the advent of misinformation, disinformation, social media, the deniers, more and more people are not vaccinating their children, which is putting the child at risk.
We’re seeing more and more outbreaks and many of these are spread by air travel.
The aviation component is what we call the vector for the infectious disease.

AVIATION PROTOCOLS FOR DISINSECTION

One component of aviation medicine is to prevent the spread of disease with protocols for what’s called disinsection. Disinsection is done through materials, chemicals, to kill bacteria and viruses.

But the vector for many diseases is an insect — mosquitoes, fleas and so on. When an airplane lands in West Africa, and they open the doors for the passengers to get out, other passengers get on. They may be insects. Nothing’s to stop a mosquito flying in, or a flea from crawling in, or even something weirder and more wonderful. Just any organic material. So you have to go through a process of disinsection.

QUESTION:

Have you transported the wounded from combat zones?

Dr. Caine: That’s called “aeromedical evacuation,” a whole field in its own right. I’ve been very involved with that because I’m a surgeon; and because I was a pilot I was flying these people very often. When I was the chief medical officer for the Israel Air Force, I was ultimately responsible for all the aeromedical evacuations carried out in Israel.

QUESTION: 

Have you had to oversee surgeries during flight?

Dr. Caine: Yes. Those surgeries are relatively small procedures. They’re essential procedures. The most common are things like inserting chest tubes, opening an airway in case somebody’s got severe facial injuries, stopping a bleed.

You don’t do major surgery in a helicopter or in a cargo plane. But you do need to do a lot of these smaller procedures.

II. HERZOG MEDICAL CENTER

QUESTION:

What is Herzog Medical Center?

Dr. Caine: I t is the oldest continuously operating Jewish hospital in Israel. It focuses on:

• mental health disorders
• respiratory illnesses
• geriatric care.

The latter two often overlap in its rehabilitation program, which includes weaning patients off of ventilators. The unusually high number of ventilated patients presents an ambulatory challenge, one which the hospital has met by expanding its sheltered underground emergency hospital.

More than once since Oct. 7, 2023, and recently with the outbreak of the US-Israel-Iran war on Feb. 28, staff successfully moved its patients underground, ensuring continuity of care, even under fire.

We’ve been operating continuously for 132 years. We were established in 1894, and were the first psychiatric hospital in the Middle East. The hospital was established in the 1880s by a group of women who identified a simple, one-room shelter that had individuals who were obviously mentally unstable. The documentation leaves a lot to be desired, but it would seem that the vast majority were young women with postpartum depression.

If you think about the squalor, the crowding, the poverty in the Old City back then, and you’re a mother who’s just had her third child, and you’re not even 20 probably, you might not even be 18, being depressed is perfectly normal.

This is one of our theories as to the hospital’s origin and why women were so interested in taking over and supporting and developing it. Originally, it was called Ezrat Nashim (the Hebrew term for the women’s section in a synagogue). It was not a maternity hospital. The original accounts from 1885 include a list of yoldot, women who have just given birth.

But it wasn’t a maternity hospital, so why did you have women who had given birth? Hence our assumption that we’re dealing with the post-partum depression. Psychiatric care didn’t exist. Psychiatric patients were put in lunatic asylums. There were also male patients. Our guess is that these are men that were probably suffering from what is called the “Jerusalem Syndrome,” when people get carried away with a spiritual sort of illusion or delusion.

Its first medical description was by one Dr. Hermann, in the Ezrat Nashim Hospital, our hospital, in the 1930s. The syndrome is still quite common in Jerusalem, but also in other other places, for example, in Rome near the Vatican, in Tzfat (Safed), in Bhutan, anywhere with a very high element of spirituality.

MENTAL HEALTH

Today the whole issue of mental health is very much in the forefront, because unfortunately what we’re seeing is a tremendous rise in stress and anxiety because of the ongoing war. You’ve got missiles flying, you’ve got people who haven’t slept in two years because they have to keep getting up and going to a shelter, especially along the northern border.

That’s just not a normal way to live. You have to think twice about going grocery shopping. You even have to think twice about having a shower. Because if you go in the shower and there’s a siren, you’ve got 90 seconds to get into a shelter if you’re in Jerusalem or Tel Aviv. If you’re on the northern border you might have only 15 seconds. So everything is a decision. Going to the bathroom is a decision. You can imagine the accumulated stress. We’ve seen a massive increase in patients that come to our outpatient clinics. We have the largest outpatient mental health clinic in the greater Jerusalem area.

We also have a highly specialized clinic dealing with stress disorders in former military people and in security forces — police, former soldiers, veterans, the Mossad. We have over 3,000 cases a month that come through.

QUESTION:

Does Herzog deal with mental health in the military context?

Dr. Caine: Before the war, we had just opened the clinic for the security forces, which we call the “Lighthouse Clinic,” Migdal Or. It was opened in collaboration with Israel’s Ministry of Defense because it didn’t have a proper clinic in the greater Jerusalem area.

Our assessment was that there are about 100 patients who will require care. So we dedicated a number of staff in the rooms and so on. We prepared everything. And then the 7th of October and all hell broke loose. From the civilian point of view, you had a massive influx, especially of youngsters.

The Ministry of Defense clinic has gone from 100 patients to 1,200. A 12-fold increase, and a waiting list of close to 2,000. If we had the physical space, and if we had the staff, we would be able to treat them, but we can’t.

So we are trying to add floors to the clinic. Even if we start today, it will take two years until we could treat that number of patients. With mental health, you’re looking at what’s going to be, because we have not reached the peak. Even if the war ends tomorrow, we wouldn’t reach the peak for something like two to five years.