Tuesday, 20 November 2012

The Army

For the last several months I have been troubled by the question of army service, and it has all felt much more acute with the current conflict. I hesitated about writing about it, partly because I still don’t have an answer, and partly because it seems like a personal issue and wouldn’t be of general interest. But it does touch on a topical Israeli matter, so I thought I’d see how it goes…
I also wrote a bit at the end about my personal views about what’s going on in Gaza (and all of Israel up to Tel-Aviv and Jerusalem).

As an immigrant doctor I am officially due to be conscripted for 18 months as a Medical Officer. I would then serve up to 1 month every year of “Millu’im” (reserve duty) until I’m 45, and be available for call-up in times of war. What is unusual about my situation is that I am being given the choice whether I want to do this (partly due to an army administrative c*#k-up). And so the big question for me is whether to volunteer?

Service in the army has historically been a big deal here: It forms an old-boys network, as proven by the number of prime ministers, cabinet ministers, and even hospital senior managers who served together in elite units.
It has also been a great social leveller: unlike Eton, Oxford and Cambridge, admission into the elite combat units tended to be from all strata of society, e.g. the current leader of the opposition (Mofaz) came from a classically under-privileged background but served as an officer in Sayeret Matkal before starting his political career.

Conversely not serving was a sign of either physical/psychological illness, or shirking of civic duty.

However, much of that has changed. Less than 50% of those who could serve actually do, and employers are no longer allowed to ask about service at interviews.

So why consider volunteering? (Or as Israelis put it: “Are you crazy?!”)
The truth is, it can’t be because the 18 months are fun or heroic. A friend (Adam Albert) wrote an excellent and funny blog describing his time as an army doctor (http://www.adndeb.blogspot.co.il), and it is tough and demoralizing: 120 hour weeks playing GP to essentially healthy, whinging 19 year olds. And I have a huge amount of respect for Adam in managing to get through it.

I am also not sure in my specific circumstance that it can be justified as being the best service to the country:
The head of my department has been suggesting various projects (e.g. research) I could do at Hadassah, some of which could definitely be more useful to Israel. In contrast, I am hardly the greatest physical athlete, or combat soldier.

Those arguments against service may well win in the end, but there still seem to be a few in favour that I haven’t been able to get around:

Firstly, it is still a big right of passage shared by most Israelis. Everyone has stories of their army service, and everywhere you go, you see people in uniform. To be Israeli and not have served makes me feel like I have missed out on a big part of what being Israeli (unfortunately) is.

Secondly, there’s no getting round the fact that it is a duty. If I volunteer and the army (unbelievably) chooses to place me in Hadassah doing research, that would be their choice. But as Ze’ev, a former boss of my mum’s put it: “Israeli men don’t use their time “usefully”; they serve their country for 3 years”.

Finally, and perhaps most positive of the reasons, is the prospect of better jobs in the future. During Milu’im you can get assigned to more special units, and I know of doctors who currently or in the past have served in such units as 669 (combat search-and-rescue/civilian helicopter evacuation), Alpianistim (the alpine trained troops in the Golan), Sayeret Egoz (elite unit of Northern Command), and Sayeret Matkal (the most elite unit in Israel and amongst the best in the world). But to do those, you must do your time as an ordinary doctor for 18 months first.

That is currently where I am at. I have agreed with my Head of Department that I will do 2 years of pure clinical training, and then we’ll see. I am currently edging towards volunteering at that stage, but the opposing pressures are great.

I know this is getting long, but I feel that I can’t finish without mentioning my experience of the recent conflict.

To start with, I wanted to say something about the political question: Was Israel right to enter into Operation Pillar of Cloud?
I see myself as firmly on the Left of the political spectrum. I believe that the Palestinians have a right to their own country and that it is in Israel’s interests for it to be independent and prosperous. My Right-leaning friends often object that the Palestinians will just use their country as a base to launch rockets, and my (admittedly slightly cynical) response is: “that’s fine”. They would then be treated like any other country that chose to launch rockets at a neighbour - it would be an act of war, and may the best army win.
Ever since I arrived here the newspapers report almost daily counts of rockets hitting towns in Israel, and they increased markedly in recent weeks. I don’t expect the British media to have covered that (it’s hardly of interest to most Brits), but it does give some context.
If we on the Left are serious about the Palestinians getting a state, than we must also be serious about that state being held accountable.

Leaving politics aside, my own experience of the war has been thankfully minor. Jerusalem has had one rocket attack, and I happened to be on holiday in the North at the time. My sister on the other hand, in Tel Aviv, has had frequent air-raid sirens and temporarily moved out of her flat to her friend’s, because it has a reinforced room.
What I did see was huge movements of troops and armoured vehicles when we were travelling on the roads (I won’t name units and where they were going on the internet). The whole atmosphere has also changed. Everyone is talking about the conflict, and some people with real anxiety.

At the moment, there is talk of a cease-fire but it’s all very vague. Let’s hope that calm will finally come to this region once and for all.

P.S. Since writing this we had another rocket hit the Jerusalem area this afternoon. I was in clinic at the time and didn’t hear the sirens (either a worrying sign about local civil defence measures, or a positive sign of how much stone and concrete was between me and the outside world!)

Monday, 10 September 2012

Medicine in Israel

So, I have now been working as an Israeli doctor for precisely 1 week and 1 day, which puts me in the perfect position to make sweeping generalisations about medicine in Israel, without the complication of experience to prove me wrong. So here goes..

But first of all, a bit about where I’m working.
Hadassah Hospital is the biggest teaching hospital in Jerusalem, and provides a whole range of specialties, including being the neurosurgical and cardiothoracic surgical centre for the area. We therefore get lots of trauma cases. We also cover a diverse population including much of the West Bank, and the Ultra Orthodox population of Jerusalem.

For the first month they have put me on the Intensive Care Unit, as a way to learn how the system in Israel works, before letting me lose as an independent anaesthetist. In 2 months time I will sit an exam, and if all goes well, will start to fly solo after that.

Now for my observations and generalisations:

Generalisation Number 1:   Medical care is hyper-specialised.
We run the “General ICU”, but there is a separate “Medical ICU” (for sick medical patients), “Neurosurgical ICU” (lots of head injuries), “Cardiothoracics ICU”, “Vascular Surgical ICU”, etc..
This means that we tend not to see the kind of multi-organ failure, medical patients that you would see in a typical British ICU.

Services are contracted out in a big way too, so when we saw a small pneumothorax (collapsed lung) on a chest X-ray, we call the cardiothoracic surgeons and they put a tube in for us (rather than do it myself as I did in England). If a patient complains of chest pain (despite minimally elevated troponin and ribs being tender), you call the cardiologist, etc..

This does seem to reduce slightly from the aura of the Intensivist as the Ultimate Physician who can treat the sickest of the sick (the hallowed status I was hoping to achieve). That title probably goes to the physicians in the Medical ICU.

Number 2:   Israelis use trade names in a huge way – which drives me crazy!
It is true that the human body is the same everywhere, and even that the treatments don’t differ so much between countries, but all that is useless if you have no idea what medical they are talking about.
We discuss how much Dantoin a head injury patient gets; most of our patients are on Lasix; all of them are on Nexium; Anyone in pain gets Optalgin (or Acamol); Patients who are agitated get Klonopin or Haldol; And if their heart is beating too fast they get Deralin or Neobloc.

It turns me into a clueless lump on ward rounds, where I am busily checking my iPhone for every medication mentioned.

Number 3:   Patient Autonomy is far more important here
In the UK:
We talk about the patient being given all the information, and making the decisions. In fact, we rarely allowed them to see investigation results, and only after we had vetted them. Getting hold of your notes took months, and you had to pay for it. The reason: Doctors know best, and patients will only get confused if they get results without explanations.

In Israel:
All GP blood results go on an online system which the patient can check from home. They would expect to discuss them with their GP, but it is not uncommon for them to read them and seek second opinions. So I get calls from family members asking why their TSH is fractionally elevated (with no symptoms and normal T4), or what to do about a minimally low folate (with no anaemia).

Similarly Do Not Resuscitate decisions seem to genuinely involve asking the family whether they want resuscitation to be carried out, as opposed to in England, where I always went into such discussions with a strong opinion of my own whether resuscitation was appropriate (generally not, if I am bringing up the subject).

Number 4:   End of life care never seems to end.
I don’t know if this is due to religious sensitivities, but there seems to be very little sense of limiting care.
So everyone (including patients in their 90s with cancer and multiple medical problems) are automatically taken to Intensive Care if they are sick, where they are given everything at our disposal. They get intubated, ventilated, started on inotropes (powerful drugs to push their heart and organs to the limits), and get full CPR. Do Not Resuscitate Decisions are very rare.

The result: frail patients spending months or years on ventilators with no chance of recovery.
Basic medical wards have their own ventilated patients, and Herzog Hospital provides entire wards for these patients to receive continuing care after they leave us.

Anyway, I don’t know how many of the non-medics will have got this far, but I thought I’d end on a bitter-sweet story from today.
We received a 22 year old girl from Ramallah with an aggressive cancer in her chest (metastatic osteosarcoma). She had a cardiac arrest on our ICU and we got her back – something which I am not at all sure was the right course of action, (but see Number 4 above).
I volunteered to sit down and break the bad news to the family, along with another trainee, Tamer (an new trainee from Bethlehem who fled from Egypt in the troubles and is now in Hadassah), who translated.
After those sorts of conversations you always feel a bit hollow inside, even though the family were extremely understanding, and even thanked us for the care we are giving her!

On the way home, on an impulse, I got off the bus a couple of stops early, and discovered another of the benefits to working here:

I stepped off the road and found myself walking for 45 minutes down slopes of Jerusalem Pine trees, towards the ancient village of Ein Karem, and the Russian Basilica there. The valley opens out before you, with Hadassah Hospital sitting like a medieval castle overlooking it all.
These photos really don’t do it justice, but after 45 minutes you can’t help but feel like your head is cleared, and you are ready to return to civilisation.

Friday, 24 August 2012

My first week as an immigrant

Just over a week ago, I left my home and job in London, and moved to set up a new life in Jerusalem, Israel.

I haven’t had a chance to call or write to all the people back home that I would like to, so in the meantime thought I’d try to keep a blog to update people occasionally on how things are going. Please do call/e-mail/snail-mail/text/FB/etc with any comments and just to say ‘hi’!

Kite Festival at the Israel Museum, Jerusalem

So to the news:
On August 13th I flew out with 71 other new immigrants to make aliyah on a chartered “Red Carpet” flight from Luton.
For those who haven’t been through this process, it is an incredible service offered by the Israeli government to new immigrants. You meet a few times with representatives in London where they start the immigration paperwork. They then give you a one-way ticket for £30 with an extended baggage allowance of 60kg. You fly out with a group of other new immigrants, and they put us all up in a hotel in Jerusalem. For the people who have never had Israeli citizenship (i.e. not me), they gave an envelope with some cash on arrival to get through the first week, and a telephone simcard, pre-charged with 200 shekels (NIS). Then at the hotel comes the best part of the entire deal – they filled a hall with all the organisations you need to get in touch with: banks, phone companies, health insurance companies, shipping companies etc. They each have a stall, and you simply go from place to place, signing up for all the services you need. Then they give you a lift to wherever you want in the country to start your new life.

Of course there were some things that still needed doing and I have been spending these first two weeks going from office to office, filling our forms for HR, Occupational Health, the army, etc. Each time I start the conversation with a slightly apologetic explanation that I am a new immigrant to the country, and so don’t really understand the system. The response I received from everyone were perhaps surprising: “Thank you”, “Mazel Tov”, “Well done”, “Besha’ah Tovah” (“in a good time”, a sort of blessing that the timing of my arrival will be good for me), “we need people like you”.

It just got me thinking. I know that there is always a place to be cynical about any country’s motivation for anything it does, but it does suggest a certain attitude towards immigration. I just remembered all the comments I heard in England about immigrants: “taking our jobs”, “changing the culture of Britain”, “burden on social services”, etc. Does Israel, with its lower rate of inflation, higher interest rates, and I believe higher rate of economic growth at the moment, have the right idea?

Now, you can’t come to Israel without being somehow affected by Middle East politics, but this time it seems to be happening quicker than I expected.
I was discussing with Ron, (my sister’s Israeli fiancĂ©) about bringing over my savings from England, and he said in all seriousness that he expects the security situation with Iran to deteriorate soon and that now many not be the best time.
The following evening around the Friday night dinner table, Sue (a close family friend) asked me if I had picked up my gas mask yet, and told me where I can get one.
I also have a friend in the army who told me, without my giving away any details, that they too are preparing in case the worst should happen.

There is no panic, and not even much fear. Just a sense from people that things are heading in a certain direction and that we mould our lives around this reality. For my part, I feel that I have come at a time when perhaps Israel needs help, and may be able to play my small part.

In the meantime I will collect my gas mask next week, and hope that I won’t be needing it and that I did indeed make aliyah “Besha’ah Tovah”.