I planned to write some three or four posts after I came back to the UK in order to convey what I feel and what has been going through my mind in this past week...but before I do, I have to say that no number of posts can ever express just how much of an affinity i feel for the west bank, both its people and the land itself. So bloody cliche to say it, but words really cannot express how much more I want to explore the area, to talk to people, to record their words and and though I gained a lot medically, I really wish I could have travelled more to see a country that is so much more than a picture in the newspaper, or a video clip on the BBC.
I travelled a little around Israel itself as well and though I have had bad experiences in Jerusalem, I would have loved to see the Golan and Galilee, Eilat, and to swim in the Dead sea (or try to at least)! Must definitely come back, and must definitely set up links so that others can see what I saw. Inshallah i will go to Gaza one day as well.
Why affiinity? Why such a deep sense of attachment?
Because I learned to live again. To wake up everyday and see something different, to challenge and want to challenge myself further. Beause it put to rest so many of the erroneous thoughts and assumptions about the world and about people. Because it showed me how life in london and how I approached it, was so lacking and so devoid of real experience, where you interact with people and expect nothing but humanity and respect in return.
Talking to a dad of three young boys on a bus to the Makassed hospital in Jerusalem, whilst he was on way to see his new baby girl. Having him translate for his oldest kid (7 years i think) who told me he wanted to be a doctor too. Hearing 'welcome to my country' in about 20 different ways and encouragement to tell him something about myself and where I was from. Seeing their smiles and seeing no mistrust, illwill or barrier between us.
Walking down the main street to the centre of town on the last night of Ramadan with a German friend in Ramallah when a group of guys on the street who were about to break fast heard us talking in English. "Are you an Arab?" in arabic they asked...I then told em I was from India and that my friend was German. There was no refusing their invite to come sit down and have Iftar with them...offering us coke, bread, rice, vegetables, chicken. Of course I had to decline the last of those, and after they asked like so many other Palestinians before them why and after telling em, they sent one of their guys to pick me up a couple of falafel sandwiches! We talked for about half an hour about where we were all from and what they did. One of em showed me two very swollen fingers and the stitches he'd had along the back of em, following an industrial machinery accident where the machine to flatten rubber had crushed his index and middle finger.
They gave me their numbers and told me to call em when I went to Hebron city. though I never did, I'll be sure to email em! And when I offered to pay for the falafels they bought for me, they were shocked and said that thats not at all polite, as I was their guest and that I should be looked after. Sure the stresses and culture is totally different in England, but seeing such a display of affection for me, a total stranger was really amazing.
Was talking to a group of mums and their kids in a paeds ward in Jerusalem in the Makassed hospital, one of em could translate almost perfectly what was being said as she'd lived in the states. Three of them were from Gaza, having been given permission by the Israelis to travel for the medical complaints of their kids. They knew I didn't speak Arabic but assumed I was Palestinian, and we talked for about 5 minutes like that, but when i told em I was a student doc from India, they just stared at me blankly for a second, and then said in arabic...'wait! you're from India? you're not from here??'....and after that welcomed me and asked me loads of questions about why I had chosen here to come to, and what I thought of the place. THey told me all about their kids, and sometimes it seemed like it didn't matter that I couldn't speak the language....they would explain their medical problems and ask me questions in arabic, only pausing to translate when it was clear that I had no clue what was being told to me. One of em asked me to definitely say her kid didn't have autism and to examine her!
But generally the openness and frank nature with which everyone acts towards each other, and the complete lack of pretention in most people, makes social interaction so much more possible, common, and honest...so that niceties and superficial politeness are present only at the beginning of a conversation before people are truly themselves with you. And disagreement is done openly...no innate worry about whether someone is out to offend you or not, or whether that statement was meant in jest or whether it was truly an offensive one. Though things are different here, and there's so much more bullshit, I'll try and incorporate this approach to interaction into my daily life.
If one thought about it, one may say that such an approach to people is unrealistic here in London, as people are different here, there is so much more crime and you can't really be yourself with people. That's true, but only up to a point, and one can determine exactly how their interaction proceeds, by not assuming the worst straight out and not expecting the person on the road, or new acquaintances to stab you in the back. Sure you don't know what they will say or how they will act. But to deal with any hostility/aggression/fear when it is encountered and to prepare for how one will react to it when one has a quiet moment, is so much more relieving, honest and even practical than anticipating attack at every corner and closing yourself off as an individual by masking. This is something that has been a struggle for me as I never quite got the balance between masking and honesty right...maybe cause I hadn't seen just what people were capable of in terms of dealing with one another. Now that I have, my perspectives are very different.
Masalam, more later.
Sunday, 4 October 2009
Saturday, 26 September 2009
Hurried Post!
Just got 15 mins to rush writing down some anecdotes. Will do more later.
Crossed two checkpoints yesterday. Apparently these road blocks used to be a daily nightmare for people wanting to visit other relatives/travel to work in other cities. What at most should be 1-2 hours of travel to most places would turn into daily treks of more than 5 hours, most of it waiting for the horde of traffic, both human and motorised to ease. These days things have improved dramatically, with soldiers only stopping vehicles now and again, usually just asking a few questions for about a minute, before allowing people to pass.
Yesterday we drove to Jenin and back to visit a surgeon's wedding, and crossed two checkpoints on the way. Your experience as much as you would like to determine it, depends on the mood of the troops manning the station. The road there crosses a number of settlements. On the way there the soldiers just waved us through paying minimal attention, but perhaps cause they had a shift change or something, stopped us twice for questions on the way back.
The first soldier was alright actually...joked around a bit, asking us what we had in the glove compartment, 'desert eagle? M16?' with a smile on his face. After being satisfied, he let us go. My friend let me know thats the second time in 6 years that he's seen a nice one. However the second soldier, this time with three or four other buddies of his, got a bit pissed off as we didn't switch our lights completely off. But no incident.
Its strange, the interaction of languages here. All road signs across the main interlinking roads are in Hebrew Arabic and English, and often arabs and israeli's have to talk to each other in English as they don't know the language of the other. Some docs who have worked in Israel or some of my friends who did manual labor on settlements recently can speak more hebrew than the norm, buts its not that common. Israeli kids are also taught Arabic in school, but not all of them keep up with it.
THe doc who was driving told me that the second checkpoint we crossed, back in the intifada during his 6th year of medical school, actually turned him back towards Ramallah after he waited 5 hours to cross it and get to Nablus. They strip searched him to underwear during the winter in full view of the people waiting in line, and then determined he wasn't safe to travel. Whether it was just the stress of the situation for everyone during that time or just cause he had a really shitty day, he ended up in an RTA, and had to be kept in ICU for 7 days.
----
Met another person who tried to scale the wall in the ER. (Yes Abdul Rahman, i'm putting this up on blogspot!) He had been trying to get across to see his kid and wife who he hadn't seen in 7 months, as he had initially gone to the OT to see his dad who wasn't well. An army jeep ran into the ladder he was on just as he was getting to the top. He fell straight down on his feet, and the impact caused a crush fracture of his vertebra, as one to his right foot. Not sure whats happened now, think he may have to go for surgery.
More later.
Crossed two checkpoints yesterday. Apparently these road blocks used to be a daily nightmare for people wanting to visit other relatives/travel to work in other cities. What at most should be 1-2 hours of travel to most places would turn into daily treks of more than 5 hours, most of it waiting for the horde of traffic, both human and motorised to ease. These days things have improved dramatically, with soldiers only stopping vehicles now and again, usually just asking a few questions for about a minute, before allowing people to pass.
Yesterday we drove to Jenin and back to visit a surgeon's wedding, and crossed two checkpoints on the way. Your experience as much as you would like to determine it, depends on the mood of the troops manning the station. The road there crosses a number of settlements. On the way there the soldiers just waved us through paying minimal attention, but perhaps cause they had a shift change or something, stopped us twice for questions on the way back.
The first soldier was alright actually...joked around a bit, asking us what we had in the glove compartment, 'desert eagle? M16?' with a smile on his face. After being satisfied, he let us go. My friend let me know thats the second time in 6 years that he's seen a nice one. However the second soldier, this time with three or four other buddies of his, got a bit pissed off as we didn't switch our lights completely off. But no incident.
Its strange, the interaction of languages here. All road signs across the main interlinking roads are in Hebrew Arabic and English, and often arabs and israeli's have to talk to each other in English as they don't know the language of the other. Some docs who have worked in Israel or some of my friends who did manual labor on settlements recently can speak more hebrew than the norm, buts its not that common. Israeli kids are also taught Arabic in school, but not all of them keep up with it.
THe doc who was driving told me that the second checkpoint we crossed, back in the intifada during his 6th year of medical school, actually turned him back towards Ramallah after he waited 5 hours to cross it and get to Nablus. They strip searched him to underwear during the winter in full view of the people waiting in line, and then determined he wasn't safe to travel. Whether it was just the stress of the situation for everyone during that time or just cause he had a really shitty day, he ended up in an RTA, and had to be kept in ICU for 7 days.
----
Met another person who tried to scale the wall in the ER. (Yes Abdul Rahman, i'm putting this up on blogspot!) He had been trying to get across to see his kid and wife who he hadn't seen in 7 months, as he had initially gone to the OT to see his dad who wasn't well. An army jeep ran into the ladder he was on just as he was getting to the top. He fell straight down on his feet, and the impact caused a crush fracture of his vertebra, as one to his right foot. Not sure whats happened now, think he may have to go for surgery.
More later.
Monday, 21 September 2009
Trauma - RTA, HBO, HBS,
Work at Ramallah general is unpredictable. You can be sitting having tea with the docs and nurses and relaxing, talking about how the day has been really quiet, when suddenly three people come in by ambulance from a road traffic accident and you don't have to time to think about anything else but what the next priority is for the patient. Its not a warzone as most people perceive this area to be, but we do see our fair share of trauma...some days way more than that.
There are three classifications for trauma patients here.
RTA (road trafffic accident)
HBO - (Hit by others [Assault, beatings, stabbings, shootings])
HBS (Hit by Soldier - any trauma inflicted by Israeli personnel)
Other trauma is simply called by mode of injury, eg. Falling down/fainting and subsequent head trauma etc.
On any day you can expect to see roughly 5-6 RTA's, more at night, and as many if not slightly more HBO's. On Fridays, when prayers at the Al Aqsa mosque are conducted, more people try and get across to ISraeli land to pray there, very often illegally and are the subject of Israeli abuse or police action, so we see more HBS those days.
An example of this sort of action was on Qadr (apologies for incorrect spelling), the night of prayer during Ramadan. People from all over the West Bank will try and get to the Al- Aqsa mosque, as one night of prayer here is equal to 50,000 prayers anywhere else. We saw a number of teenagers and young adults who tried to get over the fence due to Israeli patrols being stepped up this night along the wall. A number of kids were pulled down from the fence sufferinjg cuts to their legs as well as the occasional broken bone. I sutured two guys and their thigh wounds, and I asked one of em if he was going to try again or not...he replied with 'As soon as I'm out of the ER!'
One guy that night told me and the other docs in the history that he had been bitten by the settlers. I didn't believe him at first till I saw the bites, complete with bruising and bite marks, around the back of his arm and on his shoulder. FUcking animalistic.
On another note of HBO, one poor lady came during Eid to the ER after having been beaten severely by her husband, sustaining brusing to her chest and abdomen as well as revealing the sites of old bruises along her arms and shins. She had to be CT'd to exclude intra-abdominal bleeding. Much to my surprise, me and the ER surgeon on call were subjected to a torrent of complaints by the radiology technician, who said that as she wasn't an urgent case, she should not have been referred for CT scan. Thankfully he did shut up and do it, but I guess after having to use the limited resources available for critical RTA's and HBO's, this case didn't warrant a scan in his mind. Unthinkable thought track in any developed country.
Many of the critical and urgent trauma cases are referred to Israel to Hadassah hospital, with a much better equipped trauma centre there, and far less restrictions. Though one may have to wait an hour or two to clear the patient for transfer, I dare not think how many critical patients wouldn't make it if this option wasn't available. Two days ago I saw 4 RTA's come in, one of whom had to be transferred, after we suspected massive internal bleed and required more specialist guidance to repair the severe injuries he sustained to his chin and elbow.
Everyday we see injuries like that, and everyday I see nurses and junior residents do procedures you would be required to call an anaesthetist or specialist for in England such as emergency intubation. The worst thing is running out of equipment such as gauze or dressing sets for wounds, so that even if we have it for the RTA's, we quickly run out of it for the cases of falling down, which are mostly kids who require at least 2-3 sutures for their wounds. Oh and forget sterile technique...i lose count of how many times we've had to sterilise equipment such as needle holders and forceps by hand that should be autoclaved. One day last week, I sutured 7 people who sustained wounds to limb and scalp, often with no assistance.
That's another thing, the fact that we have nine beds and not enough doctors/nurses to attend to the patients, who keep on coming in by the tens. Some days there are intern doctors there and some days, its just me and the nurses/ senior docs on call.
Mental.
But its not just urgent trauma sustained by the mechanisms i mentioned above that come in, we see a wide range of medical emergencies such as cardiac arrest, pneumothorax and asthma, all of which i've seen at least once here.
I've seen three cardiac arrests in adult patients, one who made through alright, but the other two either sustained irreverisble brain damage, or died after 20 minutes. ATLS protocol is known but not often used properly. For example doctors here often wait to see if the patient will develop a rhythm or not at their whim, requiring us to stop CPR compressions, as opposed to conducting a rhythm check every two minutes. I have seen a hundreth of the cardiac arrest cases they have seen easily if not much less and I do not have knowledge of the research that backs up the protocol advocated by authors of British ATLS protocols. Hence I don't believe I am qualified to judge their technique. THey do follow the basics, its just the fine tuning and adaption that is carried out, that a more senior western emergency physician may object to.
I observed cardiac arrest in an infant below the age of one, who arrived dead to the ER. We resuscitated him for 20 minutes before the flat line continued for longer than the stipulated time to declare death. I will never forget the pain of the relatives, and the screaming of the mother and her throes as she heard the news will haunt me for a while to come.
Yesterday I saw critical 3rd degree burns in a 7 month old girl sustained two days prior to her coming to the ER. She had been taken by her parents to a local woman who claimed to be an expert in treating burns. TOtally unqualified medically. The equivlaent of a fucking witch doctor for all the good it did the girl. She had been dressed and bandaged twice at a cost of about 70 pounds a day, until her body finally gave out and the relatives took her to the ER. By that time the amount of fluid she had lost was too much and she died in front of our and the mother's eyes. Made me so so goddamn angry and feel so pitying for the parents, who probably knew no better than to trust the crook who claimed she could heal her.
In all that i've seen I've gone through a range of attitudes in my approach to critical patients, from feeling helpless and underqualified and sometimes unwilling to believe i could get to a stage where i could be of some use, to getting on with it but worrying i would fuck up (a very UK attitude) to now just putting the fear on the back burner and getting on with it. You know...I think I've now observed a real natural ability to put my emotion and worry away under lock and key, and just get on with it. I've told Pranjal my brother about it and he rightly says that its a valuable mentality, and one that will benefit my patients.
But I often wonder as to whether this is making me colder inside. Of course one has to get used to it dealing with the sphere of work that I have volunteered to do here and in any trauma unit across the world....but I find it difficult sometimes to remember the faces of the patients I have seen. I think I can recognize them instantly if I saw em again.
But lying down at night, its a blur to me. And it only really hit me what I had seen afterwards when I forced myself to think about it, and open the floodgates to my feelings that I had kept inside. The despair of the mother of baby who died of cardiac arrest almost was too much for me before I went to sleep, and it kept me awake. YOu don't have to understand arabic to understand what she was saying.
Fuck.
There are three classifications for trauma patients here.
RTA (road trafffic accident)
HBO - (Hit by others [Assault, beatings, stabbings, shootings])
HBS (Hit by Soldier - any trauma inflicted by Israeli personnel)
Other trauma is simply called by mode of injury, eg. Falling down/fainting and subsequent head trauma etc.
On any day you can expect to see roughly 5-6 RTA's, more at night, and as many if not slightly more HBO's. On Fridays, when prayers at the Al Aqsa mosque are conducted, more people try and get across to ISraeli land to pray there, very often illegally and are the subject of Israeli abuse or police action, so we see more HBS those days.
An example of this sort of action was on Qadr (apologies for incorrect spelling), the night of prayer during Ramadan. People from all over the West Bank will try and get to the Al- Aqsa mosque, as one night of prayer here is equal to 50,000 prayers anywhere else. We saw a number of teenagers and young adults who tried to get over the fence due to Israeli patrols being stepped up this night along the wall. A number of kids were pulled down from the fence sufferinjg cuts to their legs as well as the occasional broken bone. I sutured two guys and their thigh wounds, and I asked one of em if he was going to try again or not...he replied with 'As soon as I'm out of the ER!'
One guy that night told me and the other docs in the history that he had been bitten by the settlers. I didn't believe him at first till I saw the bites, complete with bruising and bite marks, around the back of his arm and on his shoulder. FUcking animalistic.
On another note of HBO, one poor lady came during Eid to the ER after having been beaten severely by her husband, sustaining brusing to her chest and abdomen as well as revealing the sites of old bruises along her arms and shins. She had to be CT'd to exclude intra-abdominal bleeding. Much to my surprise, me and the ER surgeon on call were subjected to a torrent of complaints by the radiology technician, who said that as she wasn't an urgent case, she should not have been referred for CT scan. Thankfully he did shut up and do it, but I guess after having to use the limited resources available for critical RTA's and HBO's, this case didn't warrant a scan in his mind. Unthinkable thought track in any developed country.
Many of the critical and urgent trauma cases are referred to Israel to Hadassah hospital, with a much better equipped trauma centre there, and far less restrictions. Though one may have to wait an hour or two to clear the patient for transfer, I dare not think how many critical patients wouldn't make it if this option wasn't available. Two days ago I saw 4 RTA's come in, one of whom had to be transferred, after we suspected massive internal bleed and required more specialist guidance to repair the severe injuries he sustained to his chin and elbow.
Everyday we see injuries like that, and everyday I see nurses and junior residents do procedures you would be required to call an anaesthetist or specialist for in England such as emergency intubation. The worst thing is running out of equipment such as gauze or dressing sets for wounds, so that even if we have it for the RTA's, we quickly run out of it for the cases of falling down, which are mostly kids who require at least 2-3 sutures for their wounds. Oh and forget sterile technique...i lose count of how many times we've had to sterilise equipment such as needle holders and forceps by hand that should be autoclaved. One day last week, I sutured 7 people who sustained wounds to limb and scalp, often with no assistance.
That's another thing, the fact that we have nine beds and not enough doctors/nurses to attend to the patients, who keep on coming in by the tens. Some days there are intern doctors there and some days, its just me and the nurses/ senior docs on call.
Mental.
But its not just urgent trauma sustained by the mechanisms i mentioned above that come in, we see a wide range of medical emergencies such as cardiac arrest, pneumothorax and asthma, all of which i've seen at least once here.
I've seen three cardiac arrests in adult patients, one who made through alright, but the other two either sustained irreverisble brain damage, or died after 20 minutes. ATLS protocol is known but not often used properly. For example doctors here often wait to see if the patient will develop a rhythm or not at their whim, requiring us to stop CPR compressions, as opposed to conducting a rhythm check every two minutes. I have seen a hundreth of the cardiac arrest cases they have seen easily if not much less and I do not have knowledge of the research that backs up the protocol advocated by authors of British ATLS protocols. Hence I don't believe I am qualified to judge their technique. THey do follow the basics, its just the fine tuning and adaption that is carried out, that a more senior western emergency physician may object to.
I observed cardiac arrest in an infant below the age of one, who arrived dead to the ER. We resuscitated him for 20 minutes before the flat line continued for longer than the stipulated time to declare death. I will never forget the pain of the relatives, and the screaming of the mother and her throes as she heard the news will haunt me for a while to come.
Yesterday I saw critical 3rd degree burns in a 7 month old girl sustained two days prior to her coming to the ER. She had been taken by her parents to a local woman who claimed to be an expert in treating burns. TOtally unqualified medically. The equivlaent of a fucking witch doctor for all the good it did the girl. She had been dressed and bandaged twice at a cost of about 70 pounds a day, until her body finally gave out and the relatives took her to the ER. By that time the amount of fluid she had lost was too much and she died in front of our and the mother's eyes. Made me so so goddamn angry and feel so pitying for the parents, who probably knew no better than to trust the crook who claimed she could heal her.
In all that i've seen I've gone through a range of attitudes in my approach to critical patients, from feeling helpless and underqualified and sometimes unwilling to believe i could get to a stage where i could be of some use, to getting on with it but worrying i would fuck up (a very UK attitude) to now just putting the fear on the back burner and getting on with it. You know...I think I've now observed a real natural ability to put my emotion and worry away under lock and key, and just get on with it. I've told Pranjal my brother about it and he rightly says that its a valuable mentality, and one that will benefit my patients.
But I often wonder as to whether this is making me colder inside. Of course one has to get used to it dealing with the sphere of work that I have volunteered to do here and in any trauma unit across the world....but I find it difficult sometimes to remember the faces of the patients I have seen. I think I can recognize them instantly if I saw em again.
But lying down at night, its a blur to me. And it only really hit me what I had seen afterwards when I forced myself to think about it, and open the floodgates to my feelings that I had kept inside. The despair of the mother of baby who died of cardiac arrest almost was too much for me before I went to sleep, and it kept me awake. YOu don't have to understand arabic to understand what she was saying.
Fuck.
Saturday, 12 September 2009
Limitations
Where do I start;
The occupation has had major effects upon business and public resources/facilities in both the West bank and Gaza. That much is plain to anyone who travels east of Jerusalem or south of Ashkelon and should not be seen as conveying a bias. What isn't so obvious is just how much of an impact has been made. Gaza is infinitely worse in standing right now in all markers of social and economic development, not least because its industrial capability is nought, totally razed to the ground during the Christmas offensive by Israel. I think their last factory was destroyed some 2-3 weeks back in an airstrike. Its situation should be discussed separately.
My friends both in the medical field here as well as those involved with the German development services (a German federal govt agency helping public institutions here) have attested to the stagnation and lack of future of the west bank. Foremost in this is the fact that almost all consumer items or the raw materials necessary to build them have to be imported from Israel. Neither the WB nor Gaza have any ports nor foreign borders that are not subject to Israeli embargo. Israeli people are forbidden from travelling to Palestinian major cities, as of 2001 with the start of the second intifada. Though there is no immediate danger of another uprising, most people here seem to think that this travel restriction is punitive, as Palestinian businesses lose their partners on the other side.
As Israel raises taxes from both its own citizens and more well to do Palestinians, it then pays the salaries of civil servants and determines how much can be used for public spending in Palestinian areas. As this amount is painfully small, WB is highly dependant on expertise and funding from foreign donors, either NGO's or foreign governments such as Norway or Germany.
The COGAT - coordinator for (israeli) govt activities in the OT, controls all water and electricity supplies to the OT, with frequent unsanctioned, illegal settlement activity responsible for tapping into what limited resources exist, such as drawing water at a lower level in the underground water table than the Palestinians have, so as to take more of it for their settlements. Saw some yesterday, looks like you've been transported to California or Switzerland with their use of water! Water is rationed to families here, and you pay for extra yourself.
Settlements along with the $5 billion Wall cut up the Palestinian territories with Settler/Jewish/tourist only roads, forcing locals to take detours of more than 45 mins to get where they want to go to. All this is the baseline...in the intifada, this was made unbearably more difficult with the establishment of checkpoints where people would wait hours and hours at before being allowed to pass. Some people in villages such as the one I'm at now, weren;t allowed to leave their towns to travel at all, relying upon the Red Crescent and other such orgnaisations to provide food.
(Israel was reluctant to compromise on control over this in the two state solution talks when Israeli PM Ehud Barak met the former Palestinian prime minister Yasser Arafat, hence why it was so hard to come to an agreement).
Most of this has been told to me in conversation so I will put some anecdotes up later. The hospital situation has some severe limitations too, most prominent of which are resources. Some of the facilities are surprisingly modern, just too few and far between.
Here are some examples...quite random but basically whatever has struck me as being wrong/odd.
There are very few beds in ICU/NICU for critical care patients, or for that matter even in normal wards. Basic first line treatments are usually available for patients but conservative treatment is often advocated for patients who would normally be admitted. Medication is reserved for harder/unresponsive patients, they often have to be transferred to other hospitals in Jerusalem or within mainland Israel. Protocols are sometimes followed but if the patient can be managed by acting minimally, this is done.
There are no transplant facilities, so all heart/kidney/liver patients who have reached the end of the line must be transfered to Israeli hospitals. I may have mentioned this to some of you, but more specialised treatments for complex conditions, eg Prostaglandin treatment to keep the Ductus Arteriosus open in neonates with critical congenital heart disease is unavailable. Such patients must also be transferred to Israel, and must pass through checkpoints that require two hours advance notice to clear the transfer as well as a list of exactly who will be travelling.
Following delivery of their child, women are kept for 12 hours, half the minimal time recommended for post natal observation of patients. Mostly to save cost and to make room for patients who need more specialised care.
The Palestinian population has one of the highest rates of cancers in the region, most likely due to the dumping of industrial waste and pollutants straight into drinking water and generally lax environmental regulations concerning waste disposal in Israel, so long as the Israeli population itself will not be affected.
One of my friends working for the German development agency within the environmental works divsion gave me the example of a factory close to the 1967 border line within mainland Israel, that produces noxious gases as a result of its operations. It is happy to operate without proper filter systems, as long as the wind blows towards the OT and WB, which it does 360 days a year. For the 3-5 days that the wind changes to blow waste back into Israel, it shuts down. This and other carcinogenic industrial processes, as well as the fact that almost 90% of Palestinians smoke, contributes to the epidemic, especially of childhood leukaemia.
Bear in mind however,that despite this situation, only basic radiotherapy and chemotherapy facilites are in place and no provisions for tumour resection. Add to this that there are virtually no trained consultant Oncologists, as should they stay here they would make roughly a 5th of the earnings they would abroad.
This has its impact upon patients in terms of unavailibility of appointments, long waiting times, and inadequate consultations. A typical clerking in ER/A&E lasts at max about 5 minutes, with most doctors taking 2-3 mins. Hardly comprehensive with only minimal attention to past med history and drugs...the focus is usally on just what the patient is coming in with. Its disturbing to often find a very blase attitude towards patients especially if they are not acute injury/emergency cases. One example is a doctor shrugging his shoulders as he continued with his evening fast breaking meal whilst a patient (newly born baby) came as a dead on arrival (DOA). True there was nothing to be done, but to do the same thing in the UK would be grounds for dismissal or at least called up to the GMC. But then after seeing so many cases day in day out and only being able to do the minimum before transfering the very sick elsewhere...I wonder sometimes if I would develop the same attitude.
Insha'allah not.
The occupation has had major effects upon business and public resources/facilities in both the West bank and Gaza. That much is plain to anyone who travels east of Jerusalem or south of Ashkelon and should not be seen as conveying a bias. What isn't so obvious is just how much of an impact has been made. Gaza is infinitely worse in standing right now in all markers of social and economic development, not least because its industrial capability is nought, totally razed to the ground during the Christmas offensive by Israel. I think their last factory was destroyed some 2-3 weeks back in an airstrike. Its situation should be discussed separately.
My friends both in the medical field here as well as those involved with the German development services (a German federal govt agency helping public institutions here) have attested to the stagnation and lack of future of the west bank. Foremost in this is the fact that almost all consumer items or the raw materials necessary to build them have to be imported from Israel. Neither the WB nor Gaza have any ports nor foreign borders that are not subject to Israeli embargo. Israeli people are forbidden from travelling to Palestinian major cities, as of 2001 with the start of the second intifada. Though there is no immediate danger of another uprising, most people here seem to think that this travel restriction is punitive, as Palestinian businesses lose their partners on the other side.
As Israel raises taxes from both its own citizens and more well to do Palestinians, it then pays the salaries of civil servants and determines how much can be used for public spending in Palestinian areas. As this amount is painfully small, WB is highly dependant on expertise and funding from foreign donors, either NGO's or foreign governments such as Norway or Germany.
The COGAT - coordinator for (israeli) govt activities in the OT, controls all water and electricity supplies to the OT, with frequent unsanctioned, illegal settlement activity responsible for tapping into what limited resources exist, such as drawing water at a lower level in the underground water table than the Palestinians have, so as to take more of it for their settlements. Saw some yesterday, looks like you've been transported to California or Switzerland with their use of water! Water is rationed to families here, and you pay for extra yourself.
Settlements along with the $5 billion Wall cut up the Palestinian territories with Settler/Jewish/tourist only roads, forcing locals to take detours of more than 45 mins to get where they want to go to. All this is the baseline...in the intifada, this was made unbearably more difficult with the establishment of checkpoints where people would wait hours and hours at before being allowed to pass. Some people in villages such as the one I'm at now, weren;t allowed to leave their towns to travel at all, relying upon the Red Crescent and other such orgnaisations to provide food.
(Israel was reluctant to compromise on control over this in the two state solution talks when Israeli PM Ehud Barak met the former Palestinian prime minister Yasser Arafat, hence why it was so hard to come to an agreement).
Most of this has been told to me in conversation so I will put some anecdotes up later. The hospital situation has some severe limitations too, most prominent of which are resources. Some of the facilities are surprisingly modern, just too few and far between.
Here are some examples...quite random but basically whatever has struck me as being wrong/odd.
There are very few beds in ICU/NICU for critical care patients, or for that matter even in normal wards. Basic first line treatments are usually available for patients but conservative treatment is often advocated for patients who would normally be admitted. Medication is reserved for harder/unresponsive patients, they often have to be transferred to other hospitals in Jerusalem or within mainland Israel. Protocols are sometimes followed but if the patient can be managed by acting minimally, this is done.
There are no transplant facilities, so all heart/kidney/liver patients who have reached the end of the line must be transfered to Israeli hospitals. I may have mentioned this to some of you, but more specialised treatments for complex conditions, eg Prostaglandin treatment to keep the Ductus Arteriosus open in neonates with critical congenital heart disease is unavailable. Such patients must also be transferred to Israel, and must pass through checkpoints that require two hours advance notice to clear the transfer as well as a list of exactly who will be travelling.
Following delivery of their child, women are kept for 12 hours, half the minimal time recommended for post natal observation of patients. Mostly to save cost and to make room for patients who need more specialised care.
The Palestinian population has one of the highest rates of cancers in the region, most likely due to the dumping of industrial waste and pollutants straight into drinking water and generally lax environmental regulations concerning waste disposal in Israel, so long as the Israeli population itself will not be affected.
One of my friends working for the German development agency within the environmental works divsion gave me the example of a factory close to the 1967 border line within mainland Israel, that produces noxious gases as a result of its operations. It is happy to operate without proper filter systems, as long as the wind blows towards the OT and WB, which it does 360 days a year. For the 3-5 days that the wind changes to blow waste back into Israel, it shuts down. This and other carcinogenic industrial processes, as well as the fact that almost 90% of Palestinians smoke, contributes to the epidemic, especially of childhood leukaemia.
Bear in mind however,that despite this situation, only basic radiotherapy and chemotherapy facilites are in place and no provisions for tumour resection. Add to this that there are virtually no trained consultant Oncologists, as should they stay here they would make roughly a 5th of the earnings they would abroad.
This has its impact upon patients in terms of unavailibility of appointments, long waiting times, and inadequate consultations. A typical clerking in ER/A&E lasts at max about 5 minutes, with most doctors taking 2-3 mins. Hardly comprehensive with only minimal attention to past med history and drugs...the focus is usally on just what the patient is coming in with. Its disturbing to often find a very blase attitude towards patients especially if they are not acute injury/emergency cases. One example is a doctor shrugging his shoulders as he continued with his evening fast breaking meal whilst a patient (newly born baby) came as a dead on arrival (DOA). True there was nothing to be done, but to do the same thing in the UK would be grounds for dismissal or at least called up to the GMC. But then after seeing so many cases day in day out and only being able to do the minimum before transfering the very sick elsewhere...I wonder sometimes if I would develop the same attitude.
Insha'allah not.
Monday, 7 September 2009
Medical experiences so far.
When I first started this blog about a month ago, I aniticipated I would update it almost every other day. For a couple of reasons it didn't play out like that, I guess it seemed somewhat unnatural. I have been learning incrementally in conversations with people what life is like here and now after the past 4 weeks I feel I am perhaps in a better position to discuss it. I should point out therefore that each subsequent post probably won't follow any set line or avenue of thought. This one will focus on some of my medical experiences.
Though having learned some information theoretically at the red crescent hospital, the fact that they require proof of some not inexpensive insurance to be presented limits signifcantly the number of patients visiting. Hence, though their specialists are good, it really wasn't the best place for a medical student to be placed. Having said that, I saw and got to help out with some pretty crazy stuff.
To give an example, I was doing an on call at roughly 4-5am about 2-3 weeks back whilst attached to gynae/obstetrics. A lady came into the ER after having just given birth to her kid in the car on the way. THe baby was delivered breech (feet first, a number of possible complications accompany that), and was totally grey and lifeless, no first cry, no breathing nothing. Apgar score of 0-1 at 1 minute and the same 10 mins later for you medics.
We took her up to the ward and for the next hour tried to resuscitate her. Some 30 mins went by with scarce improvement when we finally got her heart working again. Within half an hour she had stabalised though she did experience seizures some couple days afterwards. Learning the protocol for neonatal life support and resus in such a way made a huge impression on me and honest to God, it was one of the scariest experiences I had faced, mostly cause we barely touched on it during Paediatric rotation. About 5 mins into it, I felt the blood drain from my head and for the first time in my life I felt like I would pass out, whilst simultaneously feeling like I had to take a shit and vomit. Took every bit of resolve to stay on my feet and do what was asked of me. Thankfully that kid was for the most part ok, though I am unsure as to what long term sequelae may be faced by her.
Lord knows I went home that day and commited neonatal resus to my brain lest I ever be faced by it again before I receive formal paediatric training.
Experiences like that were very few and far between, and having gained as much experience as I could in the three weeks, I transferred to Ramallah General, the main port of call for the uninsured (almost 80% people) and people from the refugee camps. We do have quite modern equipment here as with most hospitals (this isn't Sierra Leone), although there isn't enough of it, and certain specialties lack essential facilites. I'm attached to the emergency and orthopaedic departments.
I have seen about 50 fracture cases in the 4 days here, mostly crazy kids getting too hyper and jumping around until they break something! Had to help out in a cardiac arrest/MI emergency (heart attack) and got to suture about 5 people with various cut wounds. I'm getting a lot more hands on here, but also am being challenged by doctors who would probably ace the USMLE theory exam.
After my sojorun here I still remain absolutely convinced about the necessity for a much more indepth approach to clinical teaching than what presently exists in most UK teaching hospitals, and of the need to impart a work ethic that sees the student challenging himself to no end (with due supervision of course). The few weeks working here have blown my impression of what I was capable off right out of the water. Hell I'm even considering doing the USMLE at the end of the 5th year!
I will discuss some of the limitations of the medical system in more detail in my next post.
Though having learned some information theoretically at the red crescent hospital, the fact that they require proof of some not inexpensive insurance to be presented limits signifcantly the number of patients visiting. Hence, though their specialists are good, it really wasn't the best place for a medical student to be placed. Having said that, I saw and got to help out with some pretty crazy stuff.
To give an example, I was doing an on call at roughly 4-5am about 2-3 weeks back whilst attached to gynae/obstetrics. A lady came into the ER after having just given birth to her kid in the car on the way. THe baby was delivered breech (feet first, a number of possible complications accompany that), and was totally grey and lifeless, no first cry, no breathing nothing. Apgar score of 0-1 at 1 minute and the same 10 mins later for you medics.
We took her up to the ward and for the next hour tried to resuscitate her. Some 30 mins went by with scarce improvement when we finally got her heart working again. Within half an hour she had stabalised though she did experience seizures some couple days afterwards. Learning the protocol for neonatal life support and resus in such a way made a huge impression on me and honest to God, it was one of the scariest experiences I had faced, mostly cause we barely touched on it during Paediatric rotation. About 5 mins into it, I felt the blood drain from my head and for the first time in my life I felt like I would pass out, whilst simultaneously feeling like I had to take a shit and vomit. Took every bit of resolve to stay on my feet and do what was asked of me. Thankfully that kid was for the most part ok, though I am unsure as to what long term sequelae may be faced by her.
Lord knows I went home that day and commited neonatal resus to my brain lest I ever be faced by it again before I receive formal paediatric training.
Experiences like that were very few and far between, and having gained as much experience as I could in the three weeks, I transferred to Ramallah General, the main port of call for the uninsured (almost 80% people) and people from the refugee camps. We do have quite modern equipment here as with most hospitals (this isn't Sierra Leone), although there isn't enough of it, and certain specialties lack essential facilites. I'm attached to the emergency and orthopaedic departments.
I have seen about 50 fracture cases in the 4 days here, mostly crazy kids getting too hyper and jumping around until they break something! Had to help out in a cardiac arrest/MI emergency (heart attack) and got to suture about 5 people with various cut wounds. I'm getting a lot more hands on here, but also am being challenged by doctors who would probably ace the USMLE theory exam.
After my sojorun here I still remain absolutely convinced about the necessity for a much more indepth approach to clinical teaching than what presently exists in most UK teaching hospitals, and of the need to impart a work ethic that sees the student challenging himself to no end (with due supervision of course). The few weeks working here have blown my impression of what I was capable off right out of the water. Hell I'm even considering doing the USMLE at the end of the 5th year!
I will discuss some of the limitations of the medical system in more detail in my next post.
Saturday, 5 September 2009
First Week
11th Aug.
Diary + Email entry.
Suffice to say its been a really eye opening week and half. People are so incredibly welcoming and friendly, to a level that i could not believe existed realistically. No pretense, no tiresome formalities or back biting...only a sense of dignity and hospitality that I find refreshing. And in the midst of such hardship. The second intifada (popular uprising against the day to day realities of life under occupation) ended in 2005, but still things have not really progressed at all since the time of the first peacetalks in 92, back when people thought things would resolve themsevels within the next couple of years. This level of stagnation and lack of progress has led to people being really skeptical about the future and whether things will change.
Yet they show a resilience and commitment to each other, in that they have not taken it out upon their fellow man. None of the crime you'd expect in such poor communities, but rather a real genuine attempt to maintain day to day life in the face of their struggles. I feel a hundred times safer here than I do in London!
I should say that its not as dire or as extreme a situation at all as I first envisioned. Ramallah is doing relatively better than the other West Bank palestinian cities. Other villages and towns are undoubtedly faring a lot worse, with clashes and strife against Jewish Settlers and the Israeli Defence Forces (IDF; army) being the norm, but also just a much greater degree of poverty and lack of economic security.
Next paragraph is taken from what i wrote to neeraj and pranjal. I can't be bothered to type it all out again!
know i've got my politics and i was involved as much as possible
with the gaza thing
at my uni...
i
but due to course pressure and my own conspiracy theory about israeli moss. checking my mail :P i've stayed pretty apolitical
i mean ok i have my thoughts about what took place
and what has gone on
but i can honestly say that as far as possible for me
i came here with a clean slate and open mind
and well
the reality is so much more vivid and disturbing
than i thought.
i ask open questions
when discussing politics
deliberately
to let people answer in their own words without being led
to talk about their experiences with occupation
or just hwat it was like
living
here
Work at hospital is great. Not as much hands on as i would have liked and obviously language is a major barrier (arabic is bloody hard to learn!)...but at the same time the docs here challenge me daily with management plans and differential diagnoses, to an extent that puts London to shame. At the same time there is none of this bullshit minimum competence crap that dominates king's mentality.
You are expected to know details that I would have earlier dismissed, and in doing so I honestly have realised just how much more further I can go the distance in terms of getting to grips with the reality of practicing medicine daily.
But hands on experience is lacking and so I will transfer from Red crescent to Ramallah general govt hospital next week as it sees so much more trauma/acute ER stuff, as well as a much higher burden of cases in every other department.
Diary + Email entry.
Suffice to say its been a really eye opening week and half. People are so incredibly welcoming and friendly, to a level that i could not believe existed realistically. No pretense, no tiresome formalities or back biting...only a sense of dignity and hospitality that I find refreshing. And in the midst of such hardship. The second intifada (popular uprising against the day to day realities of life under occupation) ended in 2005, but still things have not really progressed at all since the time of the first peacetalks in 92, back when people thought things would resolve themsevels within the next couple of years. This level of stagnation and lack of progress has led to people being really skeptical about the future and whether things will change.
Yet they show a resilience and commitment to each other, in that they have not taken it out upon their fellow man. None of the crime you'd expect in such poor communities, but rather a real genuine attempt to maintain day to day life in the face of their struggles. I feel a hundred times safer here than I do in London!
I should say that its not as dire or as extreme a situation at all as I first envisioned. Ramallah is doing relatively better than the other West Bank palestinian cities. Other villages and towns are undoubtedly faring a lot worse, with clashes and strife against Jewish Settlers and the Israeli Defence Forces (IDF; army) being the norm, but also just a much greater degree of poverty and lack of economic security.
Next paragraph is taken from what i wrote to neeraj and pranjal. I can't be bothered to type it all out again!
know i've got my politics and i was involved as much as possible
with the gaza thing
at my uni...
i
but due to course pressure and my own conspiracy theory about israeli moss. checking my mail :P i've stayed pretty apolitical
i mean ok i have my thoughts about what took place
and what has gone on
but i can honestly say that as far as possible for me
i came here with a clean slate and open mind
and well
the reality is so much more vivid and disturbing
than i thought.
i ask open questions
when discussing politics
deliberately
to let people answer in their own words without being led
to talk about their experiences with occupation
or just hwat it was like
living
here
past ten years
and yeah its been really eye opening
I can go into specifics later, but lets just say i feel much more comfortable talking about the reality on the ground here
having kind of in some small way
gained an appreciation
of what its like to live here....
and ramallah is doing ok
I can go into specifics later, but lets just say i feel much more comfortable talking about the reality on the ground here
having kind of in some small way
gained an appreciation
of what its like to live here....
and ramallah is doing ok
much better
than other places
and the west bank
is much better than it was 4 years ago
but at least people here don't have to go through daily checkpoints
and detours as they used to 5 years back............than other places
and the west bank
is much better than it was 4 years ago
but at least people here don't have to go through daily checkpoints
Work at hospital is great. Not as much hands on as i would have liked and obviously language is a major barrier (arabic is bloody hard to learn!)...but at the same time the docs here challenge me daily with management plans and differential diagnoses, to an extent that puts London to shame. At the same time there is none of this bullshit minimum competence crap that dominates king's mentality.
You are expected to know details that I would have earlier dismissed, and in doing so I honestly have realised just how much more further I can go the distance in terms of getting to grips with the reality of practicing medicine daily.
But hands on experience is lacking and so I will transfer from Red crescent to Ramallah general govt hospital next week as it sees so much more trauma/acute ER stuff, as well as a much higher burden of cases in every other department.
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