February 16, 2010

Met with Palestinian National Authority Minister of Health Dr. Fathi Abu Moghli, Chief of Party Dr. Taroub Faramand, Dr. Jason Prystowsky to discuss the plans for the Palestinian Medical Complex(PMC).
It is clear to me that Dr. Fathi sees the PMC as the focus and wishes for the Emergency Medicine Residency training program to be housed here. He told us that an agreement with France has already been made to establish an Emergency Medicine training program in affiliation with a university there. The details of this are to be sent to Loma Linda to review, especially as this relates to the curriculum. I have been asked to create the job description for the Medical Director of the Emergency Department. I have started on this, but have yet to visit the PMC so will add details as I learn more. He talked about “changing the culture”. He stated that anyone can learn the knowledge from textbooks but he wants to invest in changing the nursing and physician culture and change how we approach the patient including improving professionalism and compassion. He said that things change very slowly in Palestine. He said that the way the West Bank currently approaches emergency critical illness is too slow, and by the time the diagnosis is reached it is often “too late.” He wants us to become proactive rather than reactive to emergencies.He said that the MoH has an agreement with Lille University in France to build emergency medicine as a specialty at Rafidia, Hebron (Al Alia), and Qalqiliah. Our presence in the PMC will support the curriculum Lille sets forth. The Palestinian Medical Council has already drafted an emergency medicine curriculum. He requested that we make a shortlist of physicians at the PMC to create the emergency medicine leadership. He specifically stated he wanted 15 potential faculty members and stated that 5 should come from Nablus, Ramallah, and Hebron respectively. Very positive. I introduced myself. I talked about my experience building residency programs in China and at Duke University in the States. I applauded his idea of creating and emergency medicine residency program and offered Loma Linda’s technical expertise.


Terry and I took a taxi ride for lunch. We also went to the local market. The vegetables and fruits for sale were amazing. Huge strawberries, cabbages, oranges, apples, and other good things were on display in colors that would shock my Crayola Crayon box. The vendors were all vying for attention and our money. We ate falafel from a local small shop and I really like the way the women eating there at the same time smile at me. Such friendliness! I really sensed a camaraderie among women that isn’t as easy to accomplish in western culture. I managed to get away without workout clothes so found a street vendor with some sweat pants for sale. Women are not allowed to wear shorts at the gym. On the streets women are either in western clothing, or they are covered. You will see groups of women together talking and obviously friends. It is not clear to me why they choose the type of dress they do.




February 17, 2010

Second site visit to Rafidia Hospital. Met with Ayman Machaqi , Deputy Director of Administration. Mohammed Sahrawi, Director of Paramedicals served as interpreter. We discussed the administration of the hospital and noted than many of the leaders are out of town at it is the time for vacation. There is no Chief of Emergency Medicine. There had been one in place, but he has gone on vacation and it is not clear that anyone will assume this position in the near future. A maxillofacial surgeon joined us for part of the meeting and smoked. At each meeting there is someone who graciously serves us coffee or tea. The smiles are genuine and I appreciate the hospitality. I then went to the ED to learn more about process and practice. There is a senior surgical resident who serves as the resident in charge. There were 4 interns working with Dr. Samer Al-Att. The MoH assigns interns to Rafidia. They complete their year there, take an exam, and then are assigned to the type of residency they will take. Dr. Rami Nassar wants to become a psychiatrist. Dr. Muna Sharaf hopes to become a pediatrician, Dr. Ayman Sadeh would like to become a pediatrician or emergency physician, but there is no emergency medicine training program. Dr. Majie Amsour – came to consult in the ED on a surgical case, but stayed to talk with me about his frustrations with emergency care in Palestine. The interns told me that there since there is no formal training in EM, they just do the best they can and read about cases. They tell me they are basically self-taught for emergency care. They expressed a strong desire to have formal training in emergencies as they sense they are missing key diagnoses. Patient flow through the ED is rapid, but not thorough. I am certain that much is missed. Patients self-present to the main desk. The senior resident “eye-balls them” then points them to an open bed. He then sends an intern to the patient. Sicker or more seriously injured patients are seen by the senior resident who then calls in whatever consult he feels is needed. There is no tracking board. Each doctor is responsible for patient flow for his or her patients. Paper work is minimal. No required documentation other than registration and payment by the patient/family. Doctors request x-rays or CTs by filling out a form with the request. The patient’s family takes them to radiology. If the patient is too sick, staff will go with them. Nurses take off orders for labs - patients go to the lab for blood draws if they are well enough to get there, otherwise nursing or physician staff draws the blood. There is no radiology over-read unless the resident or consultant requests it. The turn-around in the ED is very rapid. Mostly because the acuity is low, and patients who are sick are moved to an inpatient unit or transferred to another hospital rapidly. There are 9 beds and there seems to be an open bed available at all times. There is an adjacent OR for patients who require immediate surgery, and a cast room. I was surprised at the amount of pediatric trauma and volume of pediatric patients. The specialty of EM is absolutely needed. With it will come a slower pace as far as patient flow as more will be done in the ED and less by consultants. There also needs to be much more attention to vital signs and pain management.

Daily report
February 14, 2010
Kathleen Clem, MD, FACEP
Arrival to Ramallah, uneventful travel. Arrived to Royal Court Suites hotel without any adverse events. Waleed Abu-Gharbiyeh was our driver. He has an excellent sense of humor. He informed us he speaks 3 languages fluently – Hebrew, Russian, (but has never been to Russia), and English. He said Arabic doesn’t count. We were greeted by Dr. Jason Prystowsky and Orrine Singer – both from Loma Linda. Met with Flagship team members for debriefing evening meeting and beginning of orientation go Flagship project and key people I will be working with. A lot of manuals, assessments, and policies to review. I couldn’t get logged on to the computer, and jet lag overcame my determination to get through everything!

February 15, 2010

We were driven by taxi to the Flagship headquarters. The project is with USAID (US Agency of International Development) and the Palestinian Health Sector Reform. This is a 5-year initiative funded by USAID in close collaboration with the Palestinian Ministry of Health (MoH). I was introduced by Dr. Taroub Faramand the Chief of Party to the other team members and leadership.

We then went to visit to Nablus to one of the key hospitals – the surgical specialty Rafidia hospital. They have pockets of excellence with all of the latest in equipment, such as orthopedic joint replacement surgery, but the Emergency Department is too small, and is under-staffed. I was given a tour of areas specifically related to Emergency Medicine. The CEO of Rafidia Hospital, Samer Awantani led the tour. Issa Badnur served as interpretor and did an excellent job! Rafidia would be an excellent sight for a Palestinian emergency medicine residency-training program created and maintained in collaboration with LLU. PMC could be one of the key training sites for emergency medicine residents. Jason spent time in the ED observing directly while I met with hospital leadership to gain information for needs assessment to start emergency medicine training program and to learn more about emergency care at this hospital. There is obvious enthusiasm and understanding of the need for EM at Rafidia. They recognize the need and verbalize understanding of the positive impact this training would have for all of Palestine. Rafidia sees 4,000 ED patients/month. There is no boarding of inpatients in the ED. If there are no inpatient beds, they transfer the patient to another hospital. Triage is non-existant, as they do not have space. The patients come back to the main desk in the ED and are seen by a physician who decides what specialists need to see the patient and then consults them. Radiology read of CTs must be requested as a consult. Anesthesia does critical care transport for patients requiring medical care, as Rafedia is a surgical hospital. Rafedia Hospital leadership states the biggest problems for emergency care are space, triage, physicians and nurses trained for emergency care, and dedicated staff. They also feel that key equipment is not available. We were served a fabulous dessert made from sheep's milk cheese and honey – then made crisp on the outside – similar to creme’ brule- I’m guessing 500 cal/serving. Good thing that was all I had for lunch and breakfast!

We then went back to Flagship headquarters to prepare a report on triage for the MoH to be instituted at the newly built Palestinian Medical Complex (PMC) new Emergency Hospital. I have not yet been to this hospital and there is some confusion as to where the USAID should focus efforts. I am willing to work with whatever is proposed, but need clear guidance. It seems that so far the PMC is not yet ready to support a new training program and that partnering with Rafidia seems a more productive road for residency training.