not to be read at the dinner table

Warning, I'm going to touch on both religion and politics. So polite company, this is not for you!

I've been asked a few times about the involvement of religion in the Israeli healthcare system. This is a topic that's difficult to confine to a blog post, and one that I'm by no means an expert in, but I'm happy to offer a few anecdotes.

Israel is a strange bird. Its a tremendously modern country that prides itself on being cutting-edge and technologically relevant, and especially in healthcare, practices tend towards the liberal side. The level of service we provide is not too disimilar from what I experienced in America. The doctors are up to date on the literature, we have all the technology you would expect in a major hospital, and the socialized system covers basic needs very nicely (prescriptions, diagnostic tests, necessary surgeries, checkups and prenatal care, and visits to specialists are all compensated).

But by nature of living in a country that holds some very large and deeply conservative communities (who wield significant political sway), we're confronted with religious issues on a daily basis.

Some examples:

-The abortion policy here is liberal to an extreme. Abortions are covered by health insurance if "medically indicated" (presence of birth defect such as Down Syndrome, cardiac defects, etc., risk to the health of the mother, unmarried mother (!))and can even be performed legally through the third trimester (although many doctors refuse to do this). I personally witnessed a mid-second trimester abortion that was performed for strictly social reasons, a teenage mother, and as liberal as I am that pushed the boundaries of my tolerance, for sure.

The hospital is very permissive (appropriately, I believe) of doctors who feel uncomfortable performing abortions for religious or personal reasons. However, doctors are required to provide prenatal counseling including genetic screening and to educate about birth control methods (which are covered by insurance).

On the flip side, many of our patients (and a percentage of physicians)are deeply conservative. The Bedouin population our hospital serves have a long history of consanguinity and a birth defects prevalence to prove it. They also tend to marry young and have as many children as possible. It's not uncommon for these patients to risk their lives, and that of their unborn child, by refusing c-sections or life-saving medical procedures because it is so important to them to preserve their fertility.

We also see quite a few patients who have refused any prenatal care or genetic testing, despite their significant risk factors, because they believe that their health is simply in god's hands. It's impossible for me to argue with their belief system, but it's difficult when complications do occur, they change their minds about healthcare, and arrive to the hospital expecting us to pick up the pieces (and to take responsibility for the outcome.)

- A small subset of the ultra-orthodox in Jerusalem have stopped vaccinating their children according to the order of their Rabbi (the health-is-in-the-hands-of-god-until-someone-actually-gets-sick argument). Within my six weeks of pediatrics, I saw four cases of measles, one of which resulted in major neurologic complications, and one which proved fatal. Again, I try to be respectful of their decision, but it's very difficult when I see children suffering for the choices of their parents. In addition, when these children come into the small emergency room with measles, they put all the immunocompromised children in the waiting room and the ward at risk.

-I completed my pediatrics rotation at a private religious hospital. This hospital remained open on Shabbat (Friday night and Saturday) BUT- no lab tests, no diagnostic imaging, and no writing. That's correct. The already understaffed ER is allowed only to provide immediately life-save services without the benefit of basic diagnostic information. In addition, they rely on volunteers to do any writing that needs to be done which slows down the already vastly backed up ER to such an extent that children with real emergency sometimes had to wait up to four hours to see a physician (who won't actually be able to diagnose or treat them fully).

In my mind, it would be better to simply close the ER and let the patients with emergencies go to a public ER where they can be treated appropriately. I volunteered one Friday evening and was so horrified I ended up leaving early. I have no problem with doctors choosing not to work on Shabbat or on closing the hospital entirely. But to provide half-healthcare in my mind is almost worse than providing nothing at all.

On the positive side, government run hospitals and clinics are fully functional through the holidays with one major exception that I wrote about in the fall.

So it's really a mixed bag here. The contrasts can be quite shocking. I don't see religion interfering too much in hospital policy. To the contrary, actually. But by the very nature of this country, it's still a daily issue, and a constant consideration.

I love neurology

"Good morning, I am Dr. Honest. This morning you will do a neurologic exam. You will do it all wrong. I will be mean. Let's go."

And that's pretty much how it went down.

Giardia

is creepy, right?

Overheard in neurology

"I tapped her knee, attempting to elicit a reflex, and accidentally shocked her into another personality."

<-- it's a good idea to read your charts.

Welcome to neurology

"It's going to be a long and terrible day." - Chief resident upon seeing us.

Apparently the neurology department is not super happy about having students.

Back to the psych ward

I'm back from a way too short six day jaunt to the states. My oh-so-typical suburban neighborhood took on a new magical shine through the eyes of my fresh off the plane husband. (It looks just like the movies!)

Today's patient of the day: In his late 40s with syphilis inspired dementia, the only way they were able to convince him to stay in the dementia ward was to tell him that he works there. He takes his work very seriously, assisting the cleaning crews, helping the nurses wheel their carts, and moving the other patients around the ward when he isn't happy with where they're sitting. Today he assigned himself the job of watching the tea pitcher and "assisting" the other patients in pouring themselves the right amount of tea. If they pour what he perceives to be the wrong amount of tea? He chastises them, takes the cup, spills it over their head, and guides them back to their seat.

The nurse seemed to feel this was benign enough not to merit intervention so we got to watch him do this about six times during our fifteen minute tour of the ward.

In other news, I managed to get hopelessly behind my training schedule for the triathlon despite my very best intentions. Luckily there are three weeks to go so I'm going to try my very best to un-jet-lag fast, make up for the lost time over the next two weeks, and then hope for the best.

article time!

The article.

You've probably already encountered it. It's about the anti-anorexia legislation passed in France.

I have mixed feelings. I do have the feeling that it's effectively impossible to be a healthy-sized female in this western universe that we inhabit and not have a hidden suspicion that life would be just a wee bit better if we were just a wee bit smaller. So I support, 100%, the idea of legislation that attempts to change pro-anorexia/pro-skinny thinking on a large-scale basis. It's amazing really. Two years in jail! I love that it's taking a stand, a bold stand. And yes, yes, yes, a change must be made. A big one.

But on the other hand I do believe in free speech. And if we're going to prosecute websites for promoting unhealthy-and-possibly-lethal lifestyle choices, we might as well shut down half the internet.

I'm on my way out to go on a bike trip in the desert with the adolescent psychiatric ward. I love this rotation. . .

On-call in the peds ER

(details changed for confidentiality of course)

A few evenings ago I spent my on-call night in the pediatric ER, one of my very favorite places of the hospital. The majority of the night was your usual mix of earaches, coughs, diarrhea, minor head trauma, an endless stream of parents who wanted antibiotics for their children's clearly viral minor illnesses, and an adorable three year old with a toy truck in his esophagus who prompted an irritating argument with the ear-nose-throat resident who didn't feel this was an emergency and wanted the child to sit in the ER with a truck in his throat until morning surgery hours. (While we agreed that the child was technically stable it's pretty tough to explain to parents that yes, we're just going to just leave the toy there until the morning because the ENT is hoping it passes on its own).

There was also a two year old with a painless limp who'd just learned how to drink from a cup and was very excited to show this off. "Cup!!" he shouted, and there went his urine sample. He was so delighted by our shocked response that he spent much of the rest of the night running up and down the hallway screaming "pee-pee!" and looking for other sample cups to drink. (Luckily the limp slowed him down enough that we were generally able to catch him before he got anything into his mouth).

And then, around 1am there was a case that stopped me in my tracks. It started out unassumingly: a really sweet young woman in high school with a few days of high fever and muscle aches. We didn't suspect anything specific but she looked really miserable so we took x-rays, drew some blood, and did a pretty thorough exam looking for a source of fever.

Everything came back negative except her blood tests: which came back abysmal, awful, worst-case-scenario. And it was like time stopped. We're thinking we'll see something consistent with a virus, with a bacteria, maybe a normal blood count- and what we get back could be a lot of things but the only thing that really explains it well (I don't even want to write it) well, it's cancer.

There was before, when we were joking with her and the parents, and after, when we ask her questions we hadn't thought relevant before: weight loss, night sweats- and she answers yes to all them, and we now need to tell her and her family that they're not going home tonight with antibiotics like they'd imagined.

I feel mildly responsible since I'm the one who took the-blood-sample-that-changed-a-life.

I've been checking on her every day and so far there are no conclusive results. We're still ruling out viruses and gallstones and she had a CT late last night that I'm going to go over and check. So it could all turn out to be nothing. I'm endlessly optimistic.

There's just something strange about the fates that led me to be there at that *moment* when the flu turned into maybe-cancer. As a student and an EMT I've been present at so many of these turning points, before-grandpa-died to after-grandpa-died, before-my-leg-was-amputated to after.

It's strange to be a witness to these seconds that turn worlds around.

To be involved and to care and to take these stories home with me at the end of the day and yet also to be completely uninvolved, really irrelevant to what they're going through- just another face in a white coat that they'll maybe remember and maybe not.

Excerpts from psychiatric interviews

-Why are you here? "I Bit off the ear of a cat." Why? "Why not?"

- How are you feeling today? "I'd like to make hamburgers from everyone's penis."

-Reason for admission: "Killed wife with a squeegee."

-Do you speak English?
"I speak every language in the world."
Great! Do you mind if I ask you some questions?
"All the words I say are bullshit. Music is the only truth. I can only talk to you if you have a guitar."
::proceeds to sing the entire rest of the interview::

-"Hasn't slept in three days. Presented to surgery department requesting general anesthesia so he could take a nap. Refused to speak to any psychiatrist other than Freud himself."


I adore psychiatry. I've always found normal people in all their normal craziness fascinating. I love that my actual job these days is to sit and just talk and get to hear all their stories. We also get to go to morning activities with the patients. Yesterday was karaoke. The picture you have in your head of psychiatric patients singing karaoke- pretty much exactly what it was like.

A surprising number of patients stop me in the hallway and tell me that they can see my soul. One told me that he can tell I have a good soul. That's always nice to hear. Another told me that he's the manager of the world and he's going to take care of everything for me. Yay!

Of course there's a difficult side: the depression and the suicides and the medical-student-syndrome of daily diagnosing myself with every psychiatric illness I've seen that given day. There are also these absolute moments of sanity and clarity from the patients, these moments that I really connect with them and enjoy them and understand them, and all of a sudden their psychosis, hospitalization, the things they've done without understanding what they've done, the things they lost. . . it's tragic really. And hard to wrap my head around.

So I keep talking to them and enjoying them and trying to find those little moments of connection. And hey, I'm getting school credit for singing karaoke.

Joy!

Overseen at lunch today (in the psychiatric hospital quad):

A dignified looking middle-aged man strolled out onto the grass where we were eating, performed a perfect back somersault, stood up, and walked away.