Ishay Lev is a family medicine resident at The Hebrew University and Hadassah Medical Center at Jerusalem, Israel. After spending more than 10 years as a fighting commander in Ramallah (a major Palestinian city next to Jerusalem) and Al-burrage (a major refugee camp next to Aza) on his regular army duty, Dr. Lev was recruited again for his first duty as a military reserve medical officer. The following diary describes the first week from a month that Dr. Lev spent as the physician of Palestinian and Israeli soldiers – detainees and jailers – in an army camp used as a prison.

This prison camp was built to accommodate Palestinian men detained before their court appearance and for short periods of imprisonment, since the initiation of the second Palestinian uprising (The Second Intifada) and usually for reasons of aiding and abating Palestinian terrorists. On arrival Dr. Lev was immediately educated on the importance of adhering to the Geneva law and representatives as well as the need to allow things to run smoothly in the camp. Confronting both of these impossible tasks during times of war is detailed in the following authentic description.

The day began with the call of the Mosque Muezzin for men from neighboring villages to come and pray. The dogs in one of the nearby villages replied as I dragged myself out of the tent to look at the sunrise. With the first beams of light, the Palestinian village lying over the hillsides above the camp seemed reluctant to awake. The soothing, gentle morning light helped me forget the aches in my back that came from sleeping in a field cot. After a shower and a shave, I made my way to the clinic's tent.

A guard barged into the clinic's tent shouting something about Cell Block 5: “He collapsed…the whole cell is storming the fences, come quick.” The medics, 30- to 40-year-old reserve men who were now on break from their daily jobs as insurance salesmen and the like, acted as if they didn't hear a thing. They continued playing chess until one of them remarked, “It's the same guy from Saturday – he was evacuated and examined at the hospital – it's nothing.” A few brisk, but friendly orders made them realize that I was serious as they rushed to get the medic bag and a gurney.

The “cell” blocks were actually outdoor compounds of tents and showers enclosed by fences and barbed wire. As we ran over, we saw almost a hundred men trying to bring the fence down, shouting “Doctor! Doctor!” The soldiers were standing in front of them pointing their guns at the crowd silently, angry, and maybe, frightened. We rushed over. The gate was already open as we approached, but there was nothing happening. The medic who was with me observed the scene casually as if it were an action movie and the end were not really relevant.

I grabbed the gurney, opened it, and took it into the cell. The inmates put their friend on the gurney and brought him out. I took his hand and looked at him – he looked OK – he was breathing; the hand was warm and of normal muscle tone and the pulse was full and regular. I sent him on to the clinic. As I came back, I stood over him and put my hand on his shoulder. I looked into his half-closed eyes for a minute and asked him in Arabic what was bothering him; he started to cry.

The rest of the examination and a liter of intravenous saline transfusion were performed not because of the urgent medical need, but because both of us wanted to keep things as “medical” as possible. I didn't ask myself what happened exactly and why the camp almost went into a riot; I did my job – that's why I thought I was there. I asked myself why I was endangering myself by going into the cell block with the gurney, and I suddenly realized that I was acting as accepted by an adult figure – one of the only ones there! A heavy load of loneliness and responsibility was suddenly back on my young physician shoulders.

Usually, the medics read out loud the prisoners' various complaints, and we would decide together on the appropriate immediate treatment or have the prisoner come in for an examination.

This morning, there was a disagreement. One of the prisoners had been complaining of a swelling in his neck. His medical file showed that another doctor saw him recently and dismissed it as a swollen gland. I told the medic to drop it and continue to follow up. The medic insisted that I see the prisoner – “something did not look right to him.” I was a bit irritated, as this specific medic always thought that something was wrong. Finally, I had no choice but to respect his wish and include the prisoner on the day's consultation list.

Around noontime, the prisoner arrived. He was a young and peaceful looking guy with no complaints, other than the lump on his neck that had been growing there for a few months. He was brought to the prison a few weeks ago. He decided to see a doctor, because for more than a week now, he could feel the lump growing. He complained about this lump once to a Palestinian doctor before he came to the camp and said that he had been administered an intramuscular injection – he doesn't know of what…the lump was very small then.

As I laid eyes on the mass on his neck, shivers went down my spine. There was a large swelling on his neck, about 5 cm in diameter, immediately above the location of the left thyroid lobe. When he swallowed, it didn't go up. When I felt it, it seemed soft – but with a hard peripheral core – and immobile. I sent the patient to do an immediate ultrasound and thyroid function test in the nearby tertiary hospital serving the inmates' needs – the Hadassah Medical Center.

I managed to forget him completely until a guard, 2 hours later, pushed the ultrasound results into my hands. The handwritten note said that they found a lesion suspected of replacing the left thyroid lobe with increased blood flow and many enlarged lymph nodes around it. The mass was not completely cystic and had no apparent calcifications.

When I told him what had been found, it seemed that the potential significance and gravity of the finding did not penetrate the cultural and language barriers. The next day, I found that the prisoner had been discharged. In prison his life might have been spared, thanks to the tertiary medicine that the prisoners were getting.

As for treatment in his own Palestinian village – I wasn't quite sure whether he was going to see a doctor again – what was I supposed to do now? A long line of prisoners compelled me to move on and leave things to be taken care of by others.

Lunch was cooked in the kitchen but served in an open tent. As I was picking up some seemingly fresh salad, the wind brought in some horrific smells with a cloud of dust and laid it peacefully on my salad. I looked at it ambiguously and sat down to eat with some of the other medics. The temperature in the tent was above 95°F; I could actually feel the gastroenteritis coming tonight.

A young soldier sat down next to us and asked for my advice about a swelling in his leg. Before I had time to postpone this consultation, he began to drop his pants. I stopped him and we set to meet in 10 minutes at the clinic tent. Still chewing some sort of canned meat, I walked up to the clinic thinking, “What do I know about muscle/bone masses?”

In the tent we continued where we had left off. While exposing his right thigh, he told me about a lump that he'd been feeling for at least 2 months. He wanted a quick review of his leg before he embarked on a few weeks' mission, so that he could decide whether it was serious enough to notify his parents, who where abroad. I questioned him about the mass (history of trauma, sting or bite, infection or any tumors in his past, etc), but no other important information came up.

While examining his thigh, I found a 15-cm-long mass along his anterolateral right thigh. There was no local heat, redness, or tenderness over the area. The mass felt like rubber with no palpable pulsation.

A week later, an orthopaedic resident, after performing an x-ray, diagnosed the lesion as a midshaft osteochondroma. I was not sure about it, especially because the location was a bit unlikely, and booked a consultation for him with a specialist to consider magnetic resonance imaging (MRI).

The young soldier accepted the findings and explanation like some young Israelis do – with the full belief that it was “nothing he couldn't handle.” By the look on his face, I knew that he was not going to tell his parents or complete the extra tests. I felt powerless.

At midnight, after visiting the prisoners' cell blocks myself and paying about 10 visits to the toilet, I asked one of the medics to brew a fresh, sweet pot of Turkish coffee, go through the guard towers, and give the soldiers on duty a hot cup. Finally, I believed that I was doing some good, and my heart got warmer and softer – I could sleep.

It was noontime, and the sun was scorching the ground and everything on it. Dust was in the air like it had a purpose of it's own, moving from one side of the camp to the other. A long line of new prisoners were waiting to be seen by me. I examined each one to see whether he was healthy, had not sustained any apparent injury, and was not contagious with anything dangerous for the whole camp. Did I learn this medicine in medical school? I must have? As I walked into the clinic's tent, I caught a glimpse of an old man sitting on the dirt looking very tired. I asked the guards to show him in first. They helped him and, slowly, he made his way in. The old man had tears in his eyes and could hardly stand. He looked about 70, although he was only 50 years old. He had severe diabetes with every target organ damaged, including borderline kidney function; he was losing his eyesight and had undergone 2 myocardial infractions. He was on some 8 medications – not all of which he could remember – and he was dehydrated.

For the first time since I came to the prison camp, I looked at an inmate's personal file. It appeared that because he looked so sick and old, he had been the perfect cover for a large store of ammunition (guns, explosives, etc) that the terrorists had hidden in his home, not necessarily with his agreement.

He was too sick to stay here and thus discharged back to his home. I felt like a doctor again but then left confused – I was treating the soldiers who were going to arrest the old Palestinian who is hiding guns in his house for the terrorists just to be released by me because of his appalling medical state! Whom was I saving by being here?

“Doctor, doctor! Get up, doctor!” The time was 2:00 am and the medics were beeping me. I answered from deep within the sleeping bag – “What?!” – not daring to stick my nose out unnecessarily. “We have work. Minor head trauma is coming in from Cell 5. Come quick.” “Conscious?” I asked. “Yes, yes – no biggie.” I put on my dusty uniform and went up to the clinic tent, rubbing my eyes.

In the dim, 24-W light, I saw the prisoner, who looked conscious, lying on the examination bed with the stitching kit already open beside him. Above the prisoner, another prisoner was standing – the prisoner's cell representative or “Shawish.” The Shawish was shouting at him in Arabic about something that I could not understand fully, and the prisoner looked like a small child being told off by his parent.

The Shawish told me how the prisoner had slipped in the shower. He also added that he thought the prisoner should go to the hospital for a computed tomographic (CT) scan and suturing – so he learnt from many other Israeli doctors before me. This explanation for the cut seemed a bit strange to me, as the injured man was fully clothed (in dry, blood-stained clothes), but I went on with my examination.

On his head, I found a 10-cm-long sharp, deep cut. Palpation did not reveal any obvious fracture of the skull. As there were no complaints of loss of consciousness, headaches, dizziness, etc, and no suspected findings on the neurologic examination, I went ahead with the suturing.

I put on the headlight that I always carry in my pocket and started with the local anesthetic.

The familiar sense of excitement of the manual labor of suturing creeped in as I lost all sense of time.

The rest of the month in the camp repeated itself, and as time went by, I started making personal friends among the soldiers and the prisoners. Small talks, Turkish coffee, personal jokes, and chess dominated my days. Slowly, the basic conditions in the camp improved, mainly for the prisoners and partly because of mine and other physicians' doings. When I went back to my home clinic in the civilian health service, I felt as if I had never left. My old-time, regular patients started paying me the welcoming visits, and we talked about my reserve service, their army time, and their urgently needed cholesterol checks. My experiences in the camp seemed quite similar to those at my home clinic but at a bigger dosage: I was taking care of things that can rarely be fixed, and my job was mainly maintenance and support. Did I learn this medicine in medical school, I must have!?