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.
