Facing a hostage situation without precedent, Israeli hospitals innovate to rehabilitate

A few days after October 7, 2023, Sheba Medical Center administrators independently took the initiative to get ready to receive hostages when they returned from Gaza.

However, since the Hamas-led terror onslaught was “unprecedented,” there was “no protocol for anything,” Dr. Noya Shilo, 46, a senior physician internist at the hospital, told The Times of Israel.

In the carnage, some 1,200 people in southern Israel were slaughtered and 251 abducted to the Gaza Strip by thousands of invading Hamas-led terrorists.

“There are few guidelines in medical literature about how to handle this,” Shilo said. The staff, she said, has had to write them.

Since then, as the war in Gaza has dragged on, Sheba Medical Center has treated 46 people who were released from captivity. Shilo is now in charge of the hospital’s Returning to Life Center, a special unit dedicated to hostages and their families, where the staff is still learning how to navigate the mostly uncharted waters of caring for returning hostages.

“We’re learning and relearning and unlearning something very needed and unknown,” Shilo said.

The Times of Israel spoke with Shilo as well as staff members at Beilinson Hospital and Schneider Children’s Medical Center, which took in some of the 139 hostages released since the war began, to understand how the medical centers developed protocols to care for people who, Shilo said, “overcame the unthinkable.”

Trans-disciplinary teams

In the days following October 7, when Shilo first heard about the hospital’s initial preparations for taking in released hostages, she discovered that no internist was involved in the project.

“You have to have an internist,” Shilo recalled telling the hospital management.  She felt a “very strong internal instinct” telling her that she had the tools needed for the project.

As the war continued to rage, she thought, “I’m not a combat soldier. I’m not a trauma expert, but this is the one thing I can do.”

Shilo joined the team. As preparations continued in earnest, the hospital hired two actors for a simulation about what it might be like to receive the released hostages.

“The only instructions for the actors were to sit in a wheelchair and look sad and moved,” Shilo said.

Then came the temporary truce at the end of November 2023, when 105 hostages were released. Sheba Medical Center treated 30 hostages during that deal, and in another wave of releases during the first few months of 2024, it treated 16 more.

The physicians work together in what Shilo calls a “trans-disciplinary” team.

“I go with a psychiatrist to see patients,” she said. “I check their heart and take blood tests, and we talk about everything. Very interesting things come up, like shortness of breath, which is very physical, but then when we talk, we realize that this very physical shortness of breath becomes worse when the patient goes in an elevator, because it’s very crowded. So we get a much deeper and more integrated version of the story of what’s going on, and that’s the way you address it.”

Shilo said the staff referenced Dr. Zahava Solomon’s longitudinal study of 1973 Yom Kippur War prisoners of war in the decades following their release, finding that the “aftermath of the trauma can reveal itself years after.”

With Solomon’s study in mind, the staff has continued to focus on ways to maintain the health of the hostages for the long term.

Most of the hostages are young people, Shilo said, so the goal isn’t “just preventive medicine.”

“We’re working with longevity experts,” she said, and then “we’re telling the hostages, ‘You have to live until you’re 100. We want you to live long, healthy, happy lives, and we’re with you.’”

Shilo also talked about Post Traumatic Stress Disorder, which is well-known, when “people sometimes get stuck or locked in their trauma, and they have ongoing symptoms which basically ruin their lives.”

Post-traumatic growth

But PTSD has a “less well-known sister,” Shilo said, Post Traumatic Growth, or PTG, a term coined by American psychologists Richard Tedeschi and Lawrence Calhoun in the early 1990s.

“People who went through severe, extreme trauma, the worst of traumas, can somehow not just learn to overcome it, but actually become stronger and find a more meaningful life,” Shilo said.

“You see enormous, enormous strength in overcoming and surviving this unbelievable atrocity,” she said. “We saw the post-traumatic growth from the beginning. We’re there to make room for it, and to do whatever we can to help each hostage on their own path, in their own pace, to get to the best place that they can.”

Shilo said it has been a “great responsibility and privilege” to work with the released hostages.

“To see them reunite with their families, reunite with their lives, taking in the unbearable pain of their losses, taking in the unbearable pain of what happened to the State of Israel, and to see them not just coping, but finding meaning in what happened — the only way I can describe my task as that I’m doing it with holy reverence,” Shilo said.

Psychological first aid for children

It is estimated that across the globe, some 2,500 to 4,000 children are abducted each year by non-state armed groups for the purposes of retaliation, intimidation, forced labor, recruitment by armed forces and sexual violence, according to the United Nations Children’s Fund.

But Prof. Silvana Fennig, a pediatric psychiatrist and director of the Schneider Children’s Hospital’s department of psychological medicine, told The Times of Israel that there are no guidelines available for treating children who have returned from captivity during a war because “it is extremely rare.”

During the hostage deal completed in November 2023, 19 children and seven mothers were treated at Schneider Children’s Medical Center.

The staff used the principles of Psychological First Aid (PFA), which is designed to help people after crisis events, but they modified the guidelines to treat children.

Fennig and four other researchers recently published their findings in the peer-reviewed journal Child Abuse and Neglect.

Fennig said one of the most important ideas they learned was to give the hostages a “transitional space, a place that isn’t fantasy and isn’t reality, but it’s not captivity.”

She stressed that they need “somewhere safe because life continues to be difficult.”

At first, the staff believed that the released hostages should leave the hospital and go home as soon as possible.

“But these captives had no home to go to,” she said. The staff learned that the former captives needed time to get back “into balance and routine,” and time “to adjust to their new reality.”

With children, she said, “It’s also very important to figure out a way to communicate bad news.”

“We learned we had to work with the families to decide who would tell children who is alive and who is dead,” Fennig explained. “Telling the news itself is also traumatic. You have to give the task to someone they know, not a therapist.”

Fennig said that the children who coped the best in captivity had a caregiver.

“Caregivers were very protective because they had to defend their kids,” she said.

It also surprised the staff that the children wanted to continue with the same routines they had while in almost two months of captivity.

“They wanted to wear the same kind of clothes that they wore in captivity,” she said. “If they were wearing short-sleeve shirts in captivity, they wanted to still wear short-sleeve shirts.”

This gives them continuity and a feeling of routine, “like reading the same story before bedtime,” Fennig said.

“It’s not as obvious to kids where they are,” she said. “Even if it’s not logical for the staff, we understood and we went with it.”

“Despite the deficiencies and the weight loss, the children did not experience anything physical that might be irreversible,” Fennig said. “However, the psychological damage is not always reversible.”

In a study of the released child hostages immediately after their release, Dr. Noa Ziv, a senior physician in the hospital’s pediatric department, and hospital staff members Dr. Yael Mozer-Glassberg and Dr. Havatzelet Yarden-Bilavsky, found the former hostages exhibited “the effects of psychological terror due to warfare strategies that included isolation, intimidation, lack of food and water, and emotional abuse.”

The long-term effects on children are still unknown.

“I cannot tell what the future holds for them,” said Fennig, “but generally speaking, children who suffer post-traumatic stress disorder might experience anxiety and depression even years later.”

Customizing protocols

Dr. Michal Steinman, director of nursing at Beilinson Hospital, also emphasized that preparing for the returning hostages was like “detective work.”

“We combined a team of physicians, nurses, nutritionists, mental health workers, social workers, and whoever we thought should be part of this unit,” she said. “We went system by system, ears, eyes, mouth, hair, skin, kidneys, urine, whatever it is, muscles, to think what is happening to a person who is under those conditions of captivity.”

From there, the staff customized protocols for 100 days in captivity, she said. But after 100 days, “we sat together again and built them for 200 days in captivity, and then for 300 days in captivity, and for 400 days in captivity, and so on.”

In February 2024, when the hospital received nine hostages, “I’m very proud to say that we thought about everything. There were no surprises. We were ready for everything. They are good protocols, but I hope for humanity that no one will ever have to use them again.”

She said that staff of the six hospitals that received the released hostages — including Soroka Medical Center, Sheba Medical Center, Wolfson Medical Center, Ichilov Hospital, Shamir Medical Center, and Schneider Children’s Hospital — shared their knowledge and worked together.

Former hostages and soldiers are in rehabilitation together

At Beilinson, the staff “made a custom-made treatment for each hostage,” Steinman said. “They still come to the hospital twice a week, and we’re still working with them personally.”

Some of the released hostages are also working with the soldiers who got injured in Gaza while trying to release them, Steinman said. “So now the hostages and the soldiers are doing rehabilitation together,” she said.

There are 59 hostages currently being held captive in Gaza. It is estimated that 21-24 of them are still alive.

Steinman said that in tandem with their own rehabilitation, the released hostages are “fighting for their brothers and sisters still in Gaza.”

“Some of the days that they are supposed to come to the hospital, they go abroad to speak with [US] President [Donald] Trump or other places,” she said. “They are not 100% in their rehabilitation process because of the other captives.”

She said that although set free, the hostages “always will have a part that stays in Gaza. When you have 500 days in captivity in Gaza, part of you will always stay there.”

As much as the staff helps the hostages, they have also taught the staff “many lessons,” said Steinman.

“How to survive and use your intelligence and all the tools that you have to survive another 24 hours, and not get crazy,” she said. “It’s amazing all the methods they developed and how they did it. They are the real meaning of a strong human spirit.”