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.
