Al Shifa Emergency Department – largest in Gaza (part 2)

See Paramedics in Gaza for original post

In part one  I gave a brief introduction to the Emergency Department (ED) at Al-Shifa hospital, Gaza’s largest healthcare facility. I spent a few hours there last week meeting staff and seeing for myself the current situation in the ED and Intensive Care Unit. In this post I’d like to focus on the shortages affecting health care provision in the ED and ICU, which are the same shortages affecting every part of the health service here.

Image

Shortages here come in a few different forms. Firstly, many drugs are scarce or completely unavailable. Secondly, many disposables (single use bits of medical equipment, such as suction tubing or syringes) are expired or unavailable. Thirdly, parts and servicing for medical equipment are often unavailable. This includes ambulances themselves, as we heard from the Ministry of Health.

The reasons for these shortages is a little complicated. The largest factor is the Israeli blockade of Gaza, which includes control of goods crossing into the country at the Kerem Shalom and Erez Crossings. This means that all imports of medical equipment must be approved and coordinated by Israel, making shipments vulnerable to delays, refusal or seizure. In the past these controls were circumvented by the smuggling of medications and equipment through tunnels under the Egypt-Gaza border. In the past the Ministry of Health, for example, have received 30% of their medicines through the tunnels. In 2013, the vast majority of these tunnels were destroyed by Egypt, cutting off a vital lifeline for Gaza and the health service in particular. As a result, shortages have been exacerbated with little hope for improvement.

Additionally, political tension between the Palestinian Authority in the West Bank and the Hamas government in Gaza can cause stalemates in the co-ordination of supplies, and widespread aid boycotts of Hamas have meant less aid and financial support for Gaza in general. Similarly, the crisis in Syria has meant that much of the aid money to Gaza has been diverted there in the last couple of years

Drug supplies in Resus

Drug stocks in Resus

But what does this mean on the ground? Firstly, the general standard of medical equipment is low – the majority of ambulances we have looked around have been outdated, unsafe and not fit for purpose. In the ED, the cubicles were each fitted with suction equipment and an oxygen supply, but the parts are old and often hard to clean. Resus, the part of the ED where the poorliest patients are taken, was generally underequipped and outdated. One 12-lead ECG machine (used for looking at cardiac rhythms and diagnosing heart attacks) used reusable suction cups instead of disposable adhesive dots. Behind was another ECG machine that was even older and apparently notoriously frustrating to use.

ECG machine with reusable suction cups

Each Resus bay had much of the equipment that I would expect to use in a full resuscitation, except it was largely single-use equipment that had been cleaned and reused. The bag-valve masks used to manually ventilate patients  were all unwrapped and reused – in the UK they are used once then thrown away due to the high risk of cross-infection and difficulty in cleaning them. Other disposables such as endotracheal tubes and syringes were being used once only, but were available in limited quantities and sizes or not at all. Additionally, many of these were out-of-date. It may seem strange that medical disposables have an expiry date, but the materials used degrade over time and they become less useful or ineffective. At work in the UK, checking expiry dates and removing expired equipment is a constant task. Donated medical supplies may be out of date or close to their expiry, exacerbating these problems in receiving hospitals.

 

These are the stocks on a quiet weekday morning – in the event of a major incident like a military assault, supplies are exhausted almost immediately. The staff here are used to the shortages – the situation has been deteriorating for years. Coming from the UK, I find it hard to grasp how they continue to work in these circumstances. I’ve worked in an ED and then the ambulance service for  5 years, and whenever I’ve wanted a drug or piece of equipment it’s been available to me. It’s not  something I ever have to worry about when deciding on treatment for a patient.

After the ED I visited the nearby Intensive Care (ICU) to see how they work. The ward was calm and clean, and a

Used disposables waiting to be washed

Used disposables waiting to be washed

doctor and nurse took the time to answer my questions while a flock of white-clad student nurses moved from patient to patient. It was only when I got deeper into conversation with a nurse later that he raised the routine reuse of equipment in the ICU and showed me the sluice where disposable equipment is washed. It was shocking to see the crates of oxygen masks, ventilator connectors and tubing piled up next to a sink, but this is the everyday situation here. I took some photos which you see below, before checking with the lead doctor that it was ok to publish them. His expression when I asked was conflicted, but after a pause he agreed.

His initial reticence made me think. By comparison, my work in the NHS is a bed of roses. I have reliable equipment, drugs and ambulances available to me, and a huge infrastructure behind me. At its best, the NHS allows me to offer the highest quality care, and I take real pride in my work. But it isn’t perfect, and occasionally I get shunted onto one of a few outdated ambulances that have been brought out of retirement since recent budget cuts started to bite. They’re barely roadworthy – they leak when it rains, break down at the worst times and look like

Bag valve masks waiting to be washed

Bag valve masks waiting to be washed

museum pieces. There’s a certain irrational twinge of shame that I feel when I work on these ambulances, when I see relatives picking at the ripped seats or the ramp gets jammed half-way up. I know that my patients deserve better, and I can provide better when I have the opportunity.

From my limited experience, I feel that a much more profound version of this feeling is what makes it hard for healthcare workers here to talk about the compromises they are forced to make to treat patients. They’re not reusing equipment out of ignorance – they know that bag valve masks are made to be thrown away after one use, that equipment has an expiry date, that better versions are available of nearly everything that they use.  They know about cross infection, best practice and what their patients need. Yet they have no option but to work with what they have to provide the best care possible in the circumstances. It adds a whole new layer of of problems to the already difficult task of caring for the sick, and they deserve better. Until something changes however, they’ll be clocking in as usual and working with what they’ve got.

Thanks to the management and staff of al-Shifa for their hospitality, and for helping me to understand the situation they work in. Thanks again to Fady for translation and introductions. Ahlan wa sahlan!

Advertisements

Tags: , , , , ,


%d bloggers like this: