Al Shifa Emergency Department – largest in Gaza (part 1)

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Last Thursday I visited Al-Shifa hospital, the largest medical complex in Gaza, to get a look at the Emergency Department (ED). I was hoping to get a better grasp on the structure of the ED, to meet some of the staff and to see for myself the situation they’re working in. I saw and learned so much that I’m going to split this into a couple of posts to make it manageable. In this post I’ll describe my visit, the structure of the hospital and touch on the role of the hospital in the recent history of Israeli military assaults on Gaza. Then in another post I’ll look at the day-to-day challenges of working in this environment with particular reference to equipment and drug shortages.

"What could have been a modern university-like hospital is, however, reduced to a completely worn-out, almost makeshift, field hospital after years of siege, as well as a lack of maintenance and upgrading." - Norwegian doctors Mads Gilbert and Erik Fosse, 2009

 

First off I met Dr Nser Al Tater, a cardiologist and the general director of the hospital who welcomed me and gave me a bit of an overview of the situation. We talked most about the impact of the electricity crisis on the hospital – I’d read details recently but to hear stories along with the statistics was eye-opening. The hospital is currently reliant on generators for 16 hours/day, requiring a huge amount of expensive and increasingly unavailable fuel. The generators aren’t designed to be used so much and have previously cut out completely – Dr Al Tater told me about a cardiac surgery where the electricity cut out ten times over the course of the operation. All life support had to be continued manually while each blackout lasted. In between, surgery resumed. Similarly, a recent powercut in the neonatal ICU resulted in staff manually ventilating 12 babies until the power returned to their ventilators.

From there we went to the medical ED to have a look around. Al-Shifa has three separate EDs – medical, surgical and obs/gynae. It’s a little confusing, although not that different in principle from my usual workplace of Leeds, where different types of patients get taken to different hospitals. I spent the most time in the medical ED – by the time I left things were getting busier and I didn’t want to get in the way so I just peeked into surgical.

Triage pathways in the ED

We were shown round the medical ED by the director, Dr Aiman Al Sahabanee. As with the ambulance depots it was nice to see how much of the department was familiar, despite the hugely different contexts. If you are a patient brought by ambulance you come through one entrance, if you self-present you register at window by another set of doors. This is exactly the same as home, just with a bit more Arabic and a bit less rain. There’s even the same security guards hanging around in case things get rowdy.

Once patients are booked in they are triaged to medical, surgical, obs/gynae or outpatients. The Al Shifa EDs see about 500 patients/day and provide free care. The medical ED has 4 doctors and 5 nurses – after triage there is a main hall with 12 beds, a suturing room, a plaster room and an ED ICU (what we call Resuscitation, or Resus in the UK) for the poorliest patients.
I got chatting to a lovely doctor who has worked in the Al-Shifa ED for over a decade after 14 years abroad. As careers go this has to be one of the toughest imaginable, yet he was very friendly and happy to chat and show me equipment. We talked about the kinds of patients that present to the Emergency Departments. Along with universally common complaints like abdo pain, cardiac problems and breathing problems, the EDs receive many trauma patients. The poor roads, creative driving and amount of kids playing in the streets result in road traffic collisions and knockdowns. The architecture of flat roofs and high windows with no child locks or safety standards mean that falls from height are common, especially with children. Assaults and gunshot wounds are also prevalent, and of course there have been huge military attacks on Gaza in recent years which flood this ED with casualties.

Cubicle in ED main area

The memories of the Gaza War (Cast Lead), Operation Pillar of Defense and countless other Israeli attacks cast a long shadow over Gaza and this Emergency Department in particular. As I approached the building I recognised the ambulance entrance from footage I’ve seen from Cast Lead where a crowd of relatives, media and police thronged the approach while car after car after ambulance after car pulled up and horrifically injured people were dragged out and inside. I’ve seen footage from inside the department during Cast Lead too, and I will never forget it. Bodies lined the floor, parents were running in unannounced clutching mutilated and clearly dead children, screaming and shouting merged together with no space to move and huge smears of blood- and in the middle of it all, doctors and staff continuing to work. It was a two minute video, years after the event, safely behind a computer screen and I’m a paramedic who has spent years working among suffering and panic. Towards the end I could only close my eyes. It was honestly a vision of hell. Two Norwegian doctors worked in the Al-Shifa ED during Cast Lead and afterwards wrote this eloquent and shocking article for the The Lancet which I would highly recommend.

Touring the department, I’m aware than most of the staff there have worked in this nightmare situation for days or weeks on end. As we walked to the ICU my friend who’d come to introduce me and translate pointed out the main entrance hall to the wing. He worked in the hospital’s blood bank during Cast Lead and saw the same hall filled with corpses after they died next door in the ED. 500 bodies lined the floor as casualties continued to arrive. At one point, 200 critically injured patients arrived in 10 minutes with no pre-alert. Remember that there’s 12 beds in the ED, plus another 3 or 4 in Resus.

resus

Resus entrance

At this point, I struggled to find common ground with the EDs back home that I know so well. I tried to imagine the ambulance bays of UK hospitals in gridlock, the corridors rammed and nurses that I know treating critical patients on the floor. It’s unimaginable but here it is reality, and a constant possibility. Every time tensions here escalate, whenever an Israeli politician calls for Gaza to be invaded again, whenever cross-border skirmishing threatens to turn into war – this is what people and especially hospital workers know would result.

After the ED I visited the nearby Intensive Care Unit which is cares for a mixture of critically ill patients. In my area in the UK we have separate ICUs for different types of patients – cardiac, trauma and neuro for example – but here they’re all in together. They have 11 beds, of which 7 were free yesterday after 3 patients were discharged before my arrival. Patients stay for as long as they need up to three months. The life support systems here have backup batteries that enable them to continue working even if the power cuts out, so they haven’t had the same electricity issues as the neonatal ICU. That said, the lead doctor explained that in terms of equipment they have ‘severe shortages in every field’.

ICU

During my visit I learned more about the shortages of medicine, equipment and disposables in the hospital and saw for myself what the staff have available to them when treating patients. I’ll write about these next time, and post some photos of the ED’s equipment for the medical types reading. For now, I’ll end this before the electricity goes – thanks for reading.

The peaceful hospital gardens. It was nice to see staff on breaks and patients resting in the sun with their families

Note – all conversations beyond general greetings and pleasantries were conducted through a translator, so there is some margin of error in everything. I haven’t fact checked the statistics and stories that I was told, but you can read many similar stories if you read more about the health care system in Gaza – you could start with this report which was written by pros rather than a paramedic trying to string a sentence together without using too many acronyms. Also, there’s variation in the way that Arabic names can be written in English, I’ve done my best. Huge thanks to the directors, co-ordinators and staff at Al-Shifa for being so welcoming. And thanks as ever to Fady for translation, introductions and lots of other help.

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