Ok. It seems from the press internationally, that all hospitals are dirty…and blame is the name of the game.

The AARP says: “DIRTY HOSPITALS.” The Jerusalem Post says: SUPERBUG!. The British papers say “SHAME ON HOSPTIALS!”

After I recovered from my own disgust at the news about issues that Nightingale had taken on 150 years ago, I have taken a different turn. First of all, the future is now, and change happens in the present. Handwashing: why is it that it seems impossible for healthcare workers to wash their hands every single time they move from room to room, from patient to patient? Why is it so difficult to do the obvious? I would say, on the front end of this, that handwashing has historically not been very sexy. It is just pitifully low tech.

Historically, it started first with Maimonides, the Rabbi/physician who stated categorically that hands had to be washed…He wrote in the Mishna Torah (2nd Law of the Talmud) “Never forget to wash your hands after having touched a sick person.” Well, that is pretty clear. He also stated that he would dismount from his horse and wash his hands prior to seeing his patients. Consistent.

Then, there was no response. In fact, no progress between 1204 to 1843. Oliver Wendell Holmes, prof of Anatomy at Harvard, identified CHildbed Fever as caused by medical students going from doing an autoposy, handling a corpse, to deliverying babies. He wrote a seminal paper on it. Still, not sexy enough. Medical professional ignored him.

Then, Semelweiss again brought handwashing up when he saw his colleage due of a puncture wound incurred while performing an autotopsy. He ordered physicians and students to wash with a mixture of Chorine and Lime juice after an autopsy. mortality dropped to 3%.

Again, he lost his job and was ignored.

It took until 1970’s for the AMA to declare handwashing the single most effective means of preventing infection.

It is now 2007. Antiseptic gels are everywhere as are signs asking patients to ask their nurses to wash their hands. However, the statistic for handwashing is still 50%.

What if handwashing were considered symptomatic of all of facility hygiene? What if hands are not washed, then the temperature at which dishes are washed is not hot enough to sterilize them or at least get them clean enough to not cause a problem? What if…

How do make staying and keeping clean sexy and high tech? Or, just plain common sense?

March 12, 2007

Now, the beginning of my second week in Israel, I go to Kaplan Hospital to see what their is to see. And, what I see are patients that are very ill, nurses and doctors providing the care that they can, and a facility whose history of caring is long and arduous. Before I describe my visit, I would like to state up front that hospitals everywhere do the best they can with what they have. Systems are unfunded; economies are stretched, levels of acuity are higher than ever. Nonetheless, only those called to the mission of caring work in healthcare these days. It is a universal truth.

Kaplan hospital, not unlike many large facilities in the US, is so spread out, that the newest part is far away from the oldest part. And, there is new and there is old. There is ‘newer’ in between. All hospitals save the wealthiest, such as the Apollo hospitals in India and those new and well-funded sites in the US, are struggling to take care of the ill. They struggle with AIDS, with cancer, with infant mortality, with all the same issues that can plague diverse population. Therefore, construction goes on to improve and build anew amidst ongoing critical illnesses and emergencies. I have yet to find any hospital that handles this with ease. But, all the hospitals work very hard at it.

Here, I describe my experience…what I saw, and what happened. This is in great respect for the patients, families, physicians, and nurses…

Kaplan Hospital…this is the reason my sister came to my house for a partial bowel resection. This was the hospital that she dreaded. She had gone through the emergency department and said she received excellent care. Then, when she was admitted, the care and situation deteriorated. Six patients in a room for three; one bathroom for ten patients. How could this be? Well, I now describe to you this hospital and what I saw and heard, and who I met. Now I understand better. And, now, I wish that I could wave a magic wand.

Here, it was clear that parts were clearly built prior to 1948. I recall finding pictures of hospitals in the 19th century…black and white photos of wards with multiple patients, families…all lined up against a wall. Well, that is where we began. the “halls” are outdoor walkways that are in need of repair….broken concrete, stone, and rails. No, they are not level nor straight. As I had not been there, it felt like a maize. Off of the maize, doors to white, tiled rooms devoid of everything except random beds, gurneys, and carts. These corridors are walkways between out buildings…not inside hallways. My sister again relives being wheeled by her husband, Bernie on these uneven walkways that are pitted…with her having this terrible peritonitus attack…she said it was awful. I know it was awful. I also know that when we are sick, everything looks so much worse…and we remember forever.

The nurses’ stations are small..functional…and only feet from several rooms. I have attached some pictures we took..it was difficult and we asked permission. I think you will get the idea from the photos. Everything is white…well, yellowed white, with some walls with punctured, all pipes and electrical wires revealed. No privacy…HIPAA does not exist, in fact may be a luxury. Here, with socialized medicine, records don’t have to be hidden from insurance companies or employers.

What was most profound to me were, as always, the staff and the patients. Here, the nurses and doctors were clearly in white coats… Funny. It made me feel safer in a way. The patients were very ill. Intensive care units were such because of the patients, not the room itself. All the rooms had moveable equipment, not stationary headboards with equipment as in the US. No TV, nothing to help patients get some psychic respite from their situation. and, the hospital itself was a ’situation.’ This is not uncommon. Many hospitals outside of the US do not have televisions…and if they do, one or two channels. I thnk that we should own the role of entertainment and distraction as a real part of pain management. From what I experienced, without anything else to think about, the pain wins.

The beds were so close together that the curtains were more of a hassle than a help. So, families merge together and patients saw and viewed each other. My sister went around with a cart of sweets to give the patients. This would never have happend in the US. These looked like homemade goodies. As she went from patient room to patient room, if she would see uncovered bare butts, she would call the nurses. Patients spoke to each other from bed to bed. Like roomates and sisters and brothers.

When I started to play this small harp, the environment did change. There are two parts of me in this. There is the HHS Susan who knows that music will change everything. THen, there is the harpist Susan who just plays and forgets and is humbled/embarassed by the response. Nothing less than stunning and immediate change. Aliza says: the staff never smile. Now, they all smile.

First, I play in the public area…this has two long tables, a TV mounted high that is on but cannot be heard, two patients. It is messy. Dissarray. Like the US, beds, carts, wheel chairs, are all lined up against the walls. crowded.

The patients love it…and I am warming up. It is hot in here. i mean really warm. In US hospitals, the temperature is kept relatively low…and patients are bundled. i think it is healthier. But, I can feel the heat from the vent in the ceiling, which also seems low.

Then, my sister rushes me into another room. There are six beds, 5 occupied. One patient is lucid…good looking man probably near 70 (since I am so old now, I am sure he is older…lots older!). His wife is with him and he loves the music. The adjacent bed, however, has a man and adult son. The man here has his eyes covered and is suffering. His son holds his hand. I move a little closer and play…I change to a Hasidic rhythm…and smiles appear. Now this suffering seems to abate and when I finish the man takes my hand. You will see the picture…of me holding the hand of the son. Maybe the light was bothering the father. But, he seemed better.

From room to room..so many suffering and the rooms are simple and bare walled, except for single electrical outlets. Old tile floors, old yellowed-white walls. Old just doesn’t look clean.

Finally, here I am in the last room in this unit. Without a doubt there were smiles and tears. I know that when one is suffering, trying to hold it together, the sound of music can be a balm to the soul. Here the harp (which admittedly does have sweet sound) and melodies unfamiliar that feel like home can bring tears of relief.

We then move on to the next unit on the 6th floor of the main hospital. Here, Lynn is a nurse educator and had planned on walking her students and me room to room. She introduces me to the nurse manager. There were many more patients. Here are the highlights:

On this unit, I am escorted by Lynne Uram, Nurse educator working with a group of new nursing students. Three of these students are American. Three of the group come in with me to each room. I spoke to them of our work in healing environments, the work of Florence Nightingale.

One patient, in her 90’s, intubated, looked deep into my eyes, and used her hands and eyes to bless me and basically say in signs that this was from God. Tears gently washed her face…and it was good. Tears welled up in me, too. How couldn’t they?

Another patient, a woman who was speaking with her physician, had just said nothing would relieve her pain. The doctor said, maybe the the music will help. As I began to play, she also began to cry. Immediate relief. Clearly, I am channeling…as I am so powerless to help.

The next room has a porch. One woman is being treated on her foot and it is painful. The music helps. But, across from her is a male prisoner..with a guard next to him on the chair. (men and women sharing the room…unheard of). He starts crying. What does it take to reach into the hearts of those suffering in a situation that robs them of their identity and holds little symbolism of hope? Maybe that is what them music brought: a small moment of the joy that seemed to be absent in this place.

The question remains, however, whether it matters that this is ISrael…but, rather, it could be anywhere…and, for some countries, undeveloped and without any resources, this is the best. In this culture…global culture, we have yet as a global community, to decide to be healthy, take care of our own, and extend the hand of good medicine across the boundaries of humanity. Until that decision is made, we shall a range of healthcare services that will be unacceptable in their lack of access to everyone, and unacceptable in subjecting the poorest to conditions that Florence Nightingale found life-threatening.

I will forever hold the blessings of the patients and their families in my heart. Even one moment of joy amidst all of this is privileged.

March 11, 2007

It is difficult to fully grasp how time has passed this year. Nonetheless, I am focussing now on sharing my experiences in Israel. I last was here in 1999, prior to the millenium, prior to 9/11, prior to the most recent intifada, prior to the war in Iraq, prior to Arial Sharon having a massive stroke, prior to the was in Lebanon. My sister, Aliza, has lived her since 1983. I am visiting her now and was on my first visit in 1999. Then, we played tourist. Now, I am visiting and able to absorb more of he normal ways of living for her.

Healthcare in Israel is state-funded. It has been socialized since the birth of the state in 1947. Not unlike the pressures in the US, the healthcare systems is plagued by lack of funding and an increasing population. Furthermore, Israel is in a state of war and the economy is terrible. So, the tax based has waned and funds are ever lessened. Few tourists.

While I am here, I will be visiting one public hospital in Rehovot, which is where my sister lives. Rehovot has a population of about 100K and is most known for being the home of the Weizmann institute, a reseach institute that is international and internationally known. Therefore, the population of Rehovot, in part, is academic, international, and English speaking. In addition, there is a very orthodox community here that lives on the southern edge of town. There are Ethiopian Jews here, making the population look more diverse. There are, however, few Arabs. A diverse Jewish population.

Rehovot is located one hour north of Jerusalem and 20 mintes from Tel Aviv. Israel is small. Smaller than Connecticut.

My sister reported to me that Rehovot is changing. Some of the small, single family homes, are being replaced with high rise apartment buildings. Why? There is an expectation that Jews from Gaza and the West Bank will be moving back into Israel proper and need housing. People live mainly in apartments here…but there are a few single homes, old…but stand alone dwellings. From what she says, this is diminishing in number as i write this.

The hospital is walking distance. Kaplan Hospital. I will visit this facility and actually perform (I brought a 26 string harp with me!) tomorrow. Aliza does volunteer work there. This is a state hospital. From what ALiza says, it is sub-standard: dirty, crowded, and unregulated. I will let you know what I see.

However, prior to my going, as I wrote for our March newsletter, there is a scandal and fear around a SUPERBUG: hospital borne infection that has killed 130 patients to date. They have not yet found an antibiotic to stop it. Furthermore, the handwashing…lack of it…is a great contributor to this problem, not unlike in the US and Britain…and I expect everywhere institutional care is housed in a single building.

Yesterday, Sunday, my sister has doctor’s appt. State clinic. Her physician was trained in Maryland, National Institute of Health. We walk into the clinic and it looks something like Southern California…kind of open, older tile floors, and the tell-tale aged yellowing walls. There is no receptionist, no insurance forms, no ‘take a number,’. I can peak slightly into the doctor’s office to see only a chair or two..obviously opposite his desk.

When we finally go inside, there is the desk with an older computer, monitor, printer on the side. The sink is behind the desk. To the left is a corner with an examination table, a role of wide what looks like paper towel, a trash can where all the used towel is pushed in, a plastic step up to the table, and a curtain that can be pulled closed. This is the physicians office and examintation room.

There is no scale. The doctor takes his own notes, pulls the record up on the computer..no charts..write and enters prescriptions. he does wash his hands when we enter and after he examins my sister. The doctor is not wearing a white coat. He is in casual clothing, casual, and is very personal with Aliza.

I asked him if he studied in the US. He said that he had studied in Maryland, at NIH. He said the physicians in the US have more resources and better salaries. However, he also said he was proud to be in Israeli physician.

Tomorrow Kaplan Hospital.