Tuesday, October 25, 2016

The Palestinian Medical Referral Process: A Study of Process in Process


Erica L Nelson
Resident in Emergency Medicine at Massachusetts General Hospital and Brigham and Women’s Hospital
PGY-4

October 16th, 2016


Anecdotes over tiny cups of Arabic coffee: the 17 year-old, traumatic head bleed patient that waited
five days for transfer for neurosurgical evaluation to a hospital located not even a 2-hour drive away. He died. The 39 year-old woman who spent 14 months at Hadassah Hospital after receiving a life-saving bone marrow transplant. She lived. The critically-ill patient that was driven to the border in a Palestinian-permit ambulance, then moved to a wheelchair to cross the border, then transferred to an Israeli-permitted ambulance for the completion of the journey. A back-to-back transfer that took an extra hour with oxygen lines and epinephrine still running. The cacophony of successes and frustrations, tragedies and man-made miracles, politics and goodwill create nothing less than a Pollock-painting when I try to disentangle the Palestinian referral process. As a physician, an empiricist, I try to step back and consider before the judgement.

First, an examination of ‘self’: How do we transfer patients in the United States from a clinic to a hospital? One hospital to the next? An institution outside of our medical record system? Is it a simple phone call, a hurried and harried hospital summary, printed labs and consultation notes, the coveted but oft-corrupted CD of imaging? Where do the referrals land?

In our Emergency Departments, there’s all too often sighs regarding incomplete documentation, a confusing narrative, the questionable reason for transfer. Time-willing, there are phone calls and faxing, curriers and clarifications. But how often do we start over, clicking through inordinate EPIC tabs to order the reportedly-normal labs ‘just to have them in our system’? Our process is not above reproach.

And with that in mind, let’s think about a cross-factional, cross-border medical referral process:

There are 4,682,467 people in the Palestinian territories, 1.4 million refugees and tens of thousands of patients that need higher levels of care. A two-year-old with acute leukocytic leukemia, that 17-year-old who sustained a traumatic sub-arachnoid, breast cancer patients, congenital heart cases, hemodialysis patients, oncology, coronary disease, orthopedics, pediatrics –thousands upon thousands of patients that need to be transferred. The infrastructural and literal violence, the administrative fragmentation and resource shortages that have created such a situation is a critical part of the conversation, but, frankly, not what I am here to address. I am here to study the complexities, realities and challenges of getting patients to the care they need.

When first conducting feasibility interviews in January, physicians (both Israeli and Palestinian) commented that there was hardly ‘a process’, but multiple variations derived from a non-standardized, ambiguous, unmonitored, untrackable system that required 1) referrals, 2) sponsorship and 3) Israeli travel permits. A whole host of complications were offered up –transfers are untimely, procedures delayed, medical information lost, sponsorship and reimbursements remain problematic. So, over the last 9 months, my research team developed a survey to understand both referring and referral-accepting MD experiences, and started building relationships with officials to obtain both Palestinian and Israeli, disaggregated referral data.

These last two weeks in Israel and Palestine have been several, tortoise-paced steps towards unfurling this project and ultimately understanding an inherently complicated process in a stochastic environment complete with multiple factions and border-crossings, two Ministries of Health, three governments, varied donors, hospital structures and perspectives. Each moment of analysis and judgement demands self-reflection and contextualization. This study of a process is very much still in process.

Wednesday, October 12, 2016

The Palestinian Medical Referral Process: A Study of Process in Process

Erica L Nelson
Resident in Emergency Medicine at Massachusetts General Hospital and Brigham and Women’s Hospital
PGY-4

October 9th, 2016

Sandwiched in between Rosh Hashanah and Yom Kippur, volleying between Jerusalem, Hebron, Ramallah, Nablus, nine different hospitals, multiple check points, cups of mint tea and strong coffee, Arabic, English, Hebrew, check-point, vibrant market, dingy office, immaculate NICU and disquieting ED, I find myself in a (needless to say), politically tricky situation. In a context wherein the origin of a mashed chickpea dip is contentious, I somehow have the audacity to attempt to examine the Palestinian/Israeli medical referral process. Even writing a blog post about it, trying to to craft each word to be perceived as politically neutral, is giving me tremendous anxiety.

Perhaps a year ago, when this project to study and potentially improve the Palestinian medical referral process started to take on solid form, I knew how wrought it would be. A feasibility assessment in January uncovered numerous interpretations of the non-standardized, untracked process that brought a Palestinian patient to East Jerusalem or Israel. A several month-long struggle with Western-trained empiricists trying to lend statistical validity to a study that inevitably could be nothing more than convenience sampling stalled international IRB processes. Imperative, quantitative data lay in distant hands, on paper, in spreadsheets, awaiting data-sharing negotiations before the woeful process of cleansing and justification even began. And politics colored every word and movement, document, grant application, border crossing and hospital visit. Nothing about this is easy.

And that, nestled beside simple human compassion and lofty Hippocratic imperatives, is why it is so compelling. The delivery of healthcare or, in this case, the delivery of patients to healthcare, is complex, context-bound, political and socio-economic. Systems that efficiently and effectively deliver healthcare, whether it be a Public Health Department or an Emergency Department, a ‘medical mission’ or a longitudinal development initiative must continuously examine the environment that surrounds their patients and their institutions. Any initiative, study, treatment plan or discharge that ignores context, will at very least lack generalizability and at worst, fail.

This reality, as an intellectual concept, is easy to understand. But the cognitive and logistical burdens it creates, the resources and time required to complete a comprehensive needs assessment and contextual analysis (of a system in crisis or a patient in crisis) often feels insurmountable. More than the tangible Likert-survey distribution and database creation, the logistical regressions and geoanalytics, this experience has been about tenacity, continuous re-calibration and humility. Whether it be in a Ministry of Health meeting or in Acute Bay 1 at Massachusetts General Hospital, these are the attributes that I must take a moment (to breathe) and summon.

Tuesday, August 2, 2016

Orthopedic Trauma Surgery in Haiti

William Slikker
Orthopedic Fellow at BWH
PGY-6


Resources in Haiti are limited and this includes the supply of surgical instrumentation. During our trip we encountered many obstacles but the most difficult to overcome was the lack of appropriate surgical instrumentation and devices that we would typically use in the U.S. For instance, there was no intra-operative fluoroscopy, which we would have normally used for a majority of the procedures we completed on the trip. It took careful planning and a dose of ingenuity to overcome the lack of instrumentation. Adapting to a foreign operating room was difficult, but the local orthopedic surgeons had much to teach us in regards to tackling surgical cases using their set of instrumentation. With the help of the Haitian orthopedic surgeons, we were able to accomplish our goal of providing safe and impactful clinical care. But by collaborating with the Haitian surgeons in this way, we also built a partnership which we hope will continue long into the future.

            This trip served to open my eyes to the complexity of international outreach and the nuances of effectively collaborating with local surgeons and staff. It taught me many things about how to successfully provide clinical care in an international setting. It also demonstrated how the short term efforts of providing direct clinical care are not as important as building bridges for education and communication in a long term grassroots effort to bolster the local medical system in which we are only temporary visitors. Although we accomplished many successful surgeries, our efforts at partnering with the local orthopedic attendings and residents will hopefully build a connection that is even more impactful in the long term.

Academic Emergency Medicine in Rural Haiti: Epilogue

Nahzinine Shakeri, MD

Resident in Emergency Medicine, Brigham and Women’s Hospital and Massachusetts General Hospital
PGY-4

      As I look back on the four weeks I spent as a visiting professor of Emergency Medicine at Hôpital Universitaire de Mirebalais (HUM) in Mirebalais, Haiti, I realize how much I gained from the experience.
As an emergency physician, I was challenged. Over the course of the month, I cared for more critically ill children than I had seen in all of residency, helped manage a mass casualty event when a tap-tap crashed, encountered patients with unfamiliar and tremendously advanced disease processes, and made indescribably difficult decisions. I learned to approach even familiar clinical situations in a new way: diagnosing bacterial meningitis clinically and starting antibiotic treatment without the confirmatory cerebrospinal fluid testing I was used to obtaining, for example, or even using a urine dipstick to check cerebrospinal fluid at the bedside for signs of infection, an evidence-based trick I learned from the brilliant and resourceful HUM residents. 
As a leader, I grew tremendously. I had spent the last year in Boston supervising junior residents at MGH and the Brigham, but always with an attending at my side. This was different. Backup was always available by phone if I needed it, but in most cases I was the most senior emergency physician in the department, acting independently and making clinical decisions on my own. While very much out of my comfort zone initially, I grew to be more comfortable in my role. I learned that I love being an attending, and I was more prepared to make this transition than I had imagined.
As a medical educator, I was inspired. During my short time at HUM, I watched the residents grow, watched them apply new skills I had taught them such as gallbladder ultrasound and chest tube placement. On one residency conference day, I collaborated with another visiting professor to create a pseudo-high fidelity simulation experience with the resources we had available to us and watched the residents approach it with excitement and focus, eager to excel and practice their skills. It was a poignant and profound realization for me that the HUM emergency medicine residents, the soon-to-be first residency trained emergency physicians in their country, are the future of emergency medicine in Haiti. They are the future bedside teachers and residency program directors and curriculum designers who will be teaching Haiti’s next generation of emergency physicians how to ultrasound gallbladders and place chest tubes and run simulations. Education, it seemed to me, was a truly sustainable intervention which would have lasting and exponentially-reaching effects, here in Haiti and everywhere.
As a citizen of the earth, I was stirred by the degree of disparity I encountered, my resolve strengthened to use my career to help alleviate suffering in underserved areas at home and abroad.
I look forward to returning to Mirebalais.

“and with that, my last shift is over and i'm off. goodbye Mirebalais. this morning i'm thinking about the amazing emergency medicine residents at HUM, the soon-to-be first emergency physicians in their country, the future of EM in haiti. and i'm thinking about the patients i cared for, a part of their tragedy and grief becoming my own. and all the amazing, dedicated, inspirational people i met here.
goodbye.. for now.”
-journal entry, 4/30

Orthopedic Trauma Surgery in Haiti

William Slikker
Orthopedic Fellow at BWH
PGY-6


My international outreach experience in Marabelias, Haiti was quite eye opening. After 8 hours of air and land travel to our hospital site, we immediately went to work seeing patients in the clinic and assisting in urgent operations that were taking place in the OR.  Similar to the U.S., it was not uncommon to encounter several severe femur and tibial fractures from motor vehicle accidents on a daily basis that needed urgent treatment. However, we did encounter more unusual injuries as well, including a machete injury cutting off half of the elbow, enormous masses of the extremities with no previous treatment, and chronic shoulder and hip dislocations which would have otherwise been corrected acutely in the U.S.


During our time in Haiti, our team accomplished more than 25 major orthopedic surgeries and evaluated upwards of 40 patients. However, we realized that although we were effective in completing surgeries, there was no way that a short term trip would have long lasting effects. Therefore, our efforts during the trip were focused on education of the local orthopedic residents and collaboration with the Haitian attending orthopedic surgeons. By fostering friendship and partnership during the trip, we hope to establish a line of communication, which will continue via phone, email, and video after our departure. In addition, we provided both clinical orthopedic books and live surgical videos to begin a library collection for the local residents. 
We are currently beta testing a live, streaming surgical video device, which would provide free, real-time interaction and consultation from Boston to the hospital in Marabelias.