I’m writing about a matter that has been burning within me the last few weeks, relating to the state of health care in Israel. As a nurse trained at New York University in the USA, I was shocked at the archaic and poor treatment that I witnessed during my grandmother’s recent hospitalization in Jerusalem. I found basic lack of protocol, and no system of accountability to ensure quality care. I’d venture to say that she was nothing short of abused by the hospital system. I hope that this story will encourage discussion regarding critical and basic changes that are essential for a quality health care system.
For some background, my grandmother is a sharp, lucid and very sweet 90-year-old woman who made Aliyah over 40 years ago, growing roots and establishing a large family in Israel. She was diagnosed with lung cancer last fall, and is currently in a home hospice program. Our story begins here. Sadly, she fell and broke her hip on Pesach of this year. She was taken by ambulance to Hadassah Ein Karem, without any pain medication, an agonizing ride for someone with a broken bone. At Hadassah, she languished in the emergency room for nearly 22 hours. She was barely provided attention, aside from pain management when it became severe. Throughout the time I was there, no one completed a head-to-toe assessment, checked her peripheral pulses, provided skin care (aside from changing diapers), or started an IV. There was no one to speak to as far as what the plan of care was, and we waited patiently for news.
The following morning, we were told they planned to transfer her to Har Hatzofim so that she could have surgery before the holiday. A single driver came to transfer her to an ambulance. With little warning, he yanked my grandmother by the sheet onto the stretcher, displacing her broken hip, causing her enormous pain. I quickly ran to find a nurse to supply pain medication before we began the bumpy ride across town. The nurse panicked, as she had forgotten to medicate my grandmother earlier, when it would have had time to take effect, and she quickly squirted a dose of Optalgin into my grandmother’s mouth. We were off. The IV, which the doctor had promised, had never been placed, so my grandmother was weak and dehydrated.
The ambulance ride was an utter horror. My grandmother was losing consciousness from the pain wracking her body, feeling every curve of the Jerusalem roads. She held my hand, closed her eyes, and was unable to speak, the pain overwhelming. I thought she would die in my arms. The care provided was negligent. The laziness, lack of protocol, and downright poor quality care was nothing short of incompetence.
I wish the story ended here, but this was the beginning of a 9-day hospital stay that reflected the same incompetency. When we arrived at the hospital, my grandmother was gravely pale, and barely able to communicate. I was in tears. The resident who was supposed to be waiting for us, as promised by the ED doctor, did not exist, and the unit secretary at Har Hatzofim had no idea what we were doing there, as they were expecting a “different” patient. As for surgery? No one had a clue. No one cared. Not priority. When I tried to probe, to request pain medications, I was yelled at, and told to calm down, because “it’s just a broken leg.” Furthermore, no one cared to assess her, on any level, since she was not yet an admitted patient. I was forced to leave her at that critical time, when I feared for her life, in order to sort out paperwork at the Admissions Office. I left my 90-year-old grandmother in the hallway of a gloomy hospital ward, dehydrated and in absolute agony, in the care (or lack thereof) of callous people. Eventually, a very kind nurse, Yulia, realized she was in distress, placed my grandmother in an empty room, and tended to her needs.
Ultimately, we paid privately so that she’d have the surgery that day. The surgeon never came by after the operation to check her, nor did any doctor until the following morning. In the interim, she spent the night in a painful hallucinatory state due to the cocktail of drugs pounding her system. I was left to contend with her alone, despite my repeated requests for help from the nursing staff. They mostly avoided my call-bells, which I understand was likely due to inadequate staffing, and when they did respond, they typically shrugged, told me this was “normal for a post-op patient,” and left the room. As the night progressed, her paranoia and hallucinations intensified and she became a danger to herself. I begged for help that was not forthcoming, until finally they restrained her to the bed. As a nurse, I know that there are multiple pathways to dealing with post-op delirium; none were employed. Had I not been present, I can assure you the night would’ve ended with my grandmother pulling out her catheter, IV and bandages, and leaping from the bed.
When the doctors were rounding the following morning, I was expelled from the unit, along with all family members visiting patients on the unit, as per policy. This ridiculous rule is a relic of the 19th century, when doctors prodded patients like specimens and preached the gospel of medicine. My grandmother, at the time, was still delirious and restrained to the bed. We, the family, had no idea what the plan for her was, and our opportunity to speak with the doctors, on rounds, was suddenly not an option. On subsequent days, we continued to be removed from the unit (which was locked), and my grandmother reported that her doctor’s visit was a mere moment in which several doctors crowded the bedside, stated her name and condition, tore back her sheet, looked at her leg, and moved on. Is there no accountability? What right do doctors have to forbid family members from attending to their loved ones at the bedside, or having an opportunity to speak with a doctor, to probe and question? This is, despite what some doctors may believe, a critical and elemental part of medicine. These doctors were essentially removing all family involvement from her care, which might have been nominally acceptable had their care been comprehensive and reassuring, but the general sense was that my grandmother was not a priority on any level, nor worthy of anyone’s time or attention.
The rest of the week was a similar hellish blur. Throughout her stay, she was not fully (or even partially) assessed once. My grandmother has lung cancer, but no one bothered listening to her lungs. Her skin was never checked for breakdown, only a cursory glance when she was being changed, nor was she repositioned, which is standard procedure every several hours on similar units in other Western countries, due to the high risk of pressure ulcers in elderly patients, especially following surgery. Nurses came to provide pain medications, often after I went searching for them, and were just as soon out of the room. One day, closer to my grandmother’s discharge date, I asked her nurse what the plan was; she responded, brutally honest, that she has no idea who my grandmother is, or even what her condition is, and therefore has no information. Can this possibly qualify as acceptable nursing care? My general sense, as a medical professional, is that my grandmother would not have survived the week had she not had a strong family presence to advocate for even the most basic care. I’ll put that differently. I believe that my grandmother would have died in, and due to, the care of an Israeli hospital.
Some more tidbits. Firstly, my grandmother’s bed, the first of three in a room that should fit two, was high enough that I needed to essentially jump and leap back if I wanted to sit on it. How on earth is an immobile post-op patient supposed to get on or off such a bed without risking further damage and an inordinate amount of pain? I fail to comprehend the logic. In the USA, a similar patient would be in a low bed (actually, all beds must be repositioned to the lowest level always) that would likely have an electronic repositioning function. At the very least, there would be special pillows that would allow the patient to be repositioned comfortably. As an alternative, I found myself stuffing multiple layers of sheets and lumpy pillows around my grandmother, which typically became so uncomfortable that she ended up flat on her back.
Secondly, when my grandmother was first wheeled into her room post-op, there was a used bag of blood draping out of the garbage pail, with blood dripping on the floor. Ultimately, I cleaned it up, since no one else seemed perturbed.
Thirdly, on some days, the only available staff to shower or clean my grandmother was young males, which was highly uncomfortable for the Orthodox, elderly woman that she is.
Lastly, while discussing her discharge, her doctors – who I’m not sure we ever met, as they communicated with us through a secretary – consistently offered wildly differing information. Ultimately, she waited several days for a bed to open up in a rehabilitation facility, only to discover – days later – that they wouldn’t accept her as a patient, only to discover that she wouldn’t have qualified anyway, since her fracture became unstable during her hospitalization (hmmm, one does wonder), and needed to be off her feet for six weeks. They then wanted to discharge her to home immediately, despite the fact that we had no infrastructure in the house, not even a proper bed, to care for an immobile person. There was no social work support to ensure the home environment was safe, nor any occupational therapy services offered. We were thrown into the water on our own, attempting to scramble the pieces together so that we could care for her safely. Upon returning home, my grandmother said she felt she had just returned from hell. Needless to say, recovering physically and psychologically from this horrifying ordeal is a gradual and lengthy process.
This level of care is an embarrassment to the state of Israel. I feel that greater emphasis needs to be placed on staffing hospitals adequately, as well as forming a standard of care, and system of accountability, that is strictly upheld. In discussion with many friends and acquaintances who have given birth in Israeli hospitals, for example, I’ve discovered a huge range of experiences, some being downright unsafe. While this is typical for any hospital, such a significant range of testimonials over the same type of care in the same hospitals indicates a problem.
I’m aware of the tremendous advances Israel – and Hadassah Hospital, in particular – has made in the field of medicine, and the medical system that allows quality comprehensive care for all socioeconomic demographics. I have great praise for these contributions to the Israeli public, and I don’t wish to negate that. However, I feel more must be done to improve healthcare, both in-hospital and in the community, to ensure patient-centered care that is comprehensive and seamless. As a nurse in the USA, I’ve seen effective models that enforce accountability, safety, protocol, standards of care, frequent assessment and rounding, and far more communication between the family and health care team, all of which were lacking in my encounter with the Israeli hospital system.
Since I first published this article as a letter to Health Minister Yael German on her Facebook page, I’ve received countless accounts of similar experiences from other people who encountered very poor care in Israeli hospitals (although I haven’t heard from Yael). I’ve received messages from nurses who care deeply, but can only express sorrow and remorse due to their inability to provide better care as a result of the lack of infrastructure, difficult conditions and inadequate staffing. I truly feel for them, as they’ve been thrust into an impossible situation. Again, I emphasize that this may not be relevant to all nurses on all units throughout Israel, but it is frequent enough that it presents as a true concern.
I’d also like to note that Hadassah Hospital has since completed a thorough investigation of my grandmother’s care, and their reports deduce that my grandmother received “very good medical treatment at Hadassah,” and the Orthopedic Department Head stated that he “was impressed by the quality of care.” They noted certain areas that require improvement, and expressed desire to do so, but by and large minimized some of the gross errors present in my grandmother’s care. While I greatly appreciate their readiness to investigate seriously, I am disappointed that they a) whitewashed several matters of deep concern, and b) were unwilling to look beyond what was merely documented by the doctors and nurses involved in my grandmother’s care. Clearly, it is easier for providers to document thoroughly than it is to provide quality care that honestly reflects their documentation. Obviously, the records indicate that my grandmother “was treated properly including position changing, pain treatment, mobility progress, surgery wound treatment, etc.,” but I am quite certain that the treatment she received was not legitimately reflected in their reports.
Sadly, “covering up” poor care will not benefit the hospital or its patients in any way, though it obviously prevents a lawsuit. It is not my intention to blaspheme or bad-mouth Hadassah, since I truly honor their incredible work, and I’m certain that this type of care is not the the standard. I do hope, however, that the people orchestrating care, and those providing it at the bedside, might reflect on established protocols and whether they are really being lived up to in a manner that reflects the mission statement of Hadassah. Perhaps, someone will use this opportunity to create change on the hospital units, not in a punitive manner, but one that embraces the challenges of medical/nursing care and seeks to streamline and improve the experience for both providers and patients.
I’d like to thank the few providers – Yulia and Dima, especially – who were attentive, kind and professional, demonstrated compassionate care, and took the time to treat my grandmother in a manner that minimized her pain. Yulia, especially, was the nurse who observed my grandmother in distress when she arrived on the unit following her transfer, and went out of her way to intervene. She was also on shift later that night, when my grandmother was restrained, and my only comfort at the time was the knowledge that she went about her task in a sensitive manner. I was always relieved to see either of them on shift, and I sensed their genuine concern. I will always be grateful.
As I seem to have hit an impasse (though I intend to persevere), I urge those of you who have had similar experiences to come forward and share your stories with the hospitals in question, political figures, the media, and your friends. Perhaps, if enough concern is generated, hospitals and lawmakers will understand the need to reflect on policy, staffing, accountability and protocol issues, and establish change that will only benefit and improve the care provided in Israeli hospitals.
I wish you all the best of health.