A familiar story

The story is a bit too familiar.  Another young man from Sudan or Eritrea was shot by Egyptian soldiers while trying to cross into Israel.  Flipping through his chart, I see he was medevac’d to Soroka University Medical Center and treated there.

He broke into a smile when I said he studied there, so his experience at Soroka couldn’t have been too terrible.  I felt a bit of pride at that, even though I hadn’t been involved in his care.  I feel pride in Israel for saving his life, even if he was later dumped on the street with just a conditional release document rather than having his asylum claim actually considered.  As if people are risking the things that happen in the Sinai for the economic privilege of washing dishes in Tel Aviv.

The “conditional release” does not forbid this young man from working, but it also doesn’t give him permission to work, which limits his access to the legitimate job market, where his employer would be required to provide him with foreign worker health insurance, which would be not unlike the insurance I have as a foreign student.

It’s two years later, and he continues to have pain and disability from the wound, which is why he is here at the free clinic. Unless a lot changes, or rather, unless one simple policy changes, any further medical care he gets, future surgeries, rehabilitation, pain management, will depend on charity.

I think medical privacy prevents me from telling you his age, but he is far too young for this burden.

Staples and Stoicism

I was on the train back to Beer Sheva, answering practice test questions on my laptop, when I remembered the look on David’s* face and my stomach lurched. I was on my way back from volunteering at a free clinic, where I’d been helping one of the nurses. David was the first patient to come in, and the crown of his head was wrapped with bandages.
The nurse read over his letter from the hospital, which said that he needed his stitches removed today. So this, she told me, is something that the nurses do, and it is a quiet day here, so we’ll just do it here in the triage room. She asked me if I’d ever removed stitches and staples, and when I said that I hadn’t she suggested I come and learn. We went with David and his friend into the adjacent nursing station, and the nurse gathered her tools: bandages, chlorhexidine, and a gadget for removing medical staples that was not unlike the one used in offices to remove regular staples.
She removed the bandages from his head. Underneath, his close-cropped hair was matted with scabs, dried blood, and crusts. Stitches and staples snaked around the top and right side of his head, still abraded and swollen with bruises. She showed me how to remove a staple, and then handed me the tool.
“Try it,” she suggested.
I put on gloves; they were too big and flopped over the ends of my fingers. I placed one hand lightly on the unscathed side of his head, to tilt it to the right angle but also hoping to be reassuring, before getting to work.
It wasn’t hard: slide the bottom teeth under the staple, squeeze it, and out comes the staple, bent into an “M” shape. I started with the staples in areas that had healed cleanly and these first dozen or so came out easily; then I turned to the ones in the abraded and scabbed areas. It was often hard to get the tool under the staple because of scabs adhering to the staples. I tried wetting the scabs with more chlorhexidine to soften them. And then there was inserting the tool against tender areas. David sat there stoic, but when I struggled to insert the gadget in the messier areas I heard his sharp intakes of breath and I could feel his body tense. A few of the staples seemed to have rotated and I had to work them around to be right-side up before I could pull them out. Blood started to trickle down his temple and I patted at it with more gauze and chlorhexidine. It occurred that the worst thing I could do was hesitate once I had both of the teeth under the staple; the kindest thing was to work fast and smooth and get it right on the first try.
When I was done with the staples, and they were piled neatly on the counter, I double-checked that there were none left in his head, and then shook his hand. “Kol hakavod,” I told him. “You have a lot of strength.” He laughed, and motioned that he wanted the staples. His friend found a bag, I scooped up the staples, and he smiled and tucked it away in his pocket. I went to find the nurse to learn what to do about the stitches.
The nurse showed me how to take the pinchers, grab the end of the suture, pull it taut and cut it with a scalpel blade right below the knot, and then pull the suture through and out. I took the tools, and started with the next suture, but I struggled to find the knot beneath the scabs. I moved to another set of stitches with less scabs, and the first few came out more easily, and then it was on to the harder ones. The sutures I was pulling out were often covered in scabs and ooze, and occasionally, fresh blood.
Finally David stopped me, and motioned to me to wash the wounds again with chlorhexidine before continuing. As I started to do so, his friend explained that he was never going to say that he couldn’t take the pain, but that he needed a break. I washed the wounds twice over, taking my time, trying to moisten and soften the scabs while giving him as much time as I could. Then I picked up my tools again.
At one point I realized that left hand was trembling as I worked, and that I had been at all of this for almost an hour. I switched the scalpel to my steadier right hand, and worked at grasping the blue plastic sutures with the pincher in my left hand. The last ones that I did were so encrusted in scabs that finding the ends meant digging through the scabs and reopening them. Every move led to a sharp intake of breath from David.
When I finished removing the sutures and they were piled up spider-like, dabbed with scabs and pus, I offered David my hand again and told him he had a lot of strength. We agreed to throw out the sutures, since they were disgusting, leaving just the staples as a souvenir. The nurse instructed me to bath his head in polidine, and taking more gauze, I slowly traced over and over the maze of torn and healing skin on his scalp, hoping that it would be enough to prevent infection from setting in.
Later, on the train, after helping out in the pharmacy with other students, finding medicines for patients, after listening to the stories from another pretty amazing nurse and catholic nun, after learning from her how to draw pus out of a wound with hydrogen peroxide, after walking back to the bus with a patient and a volunteer translator heading for the same way, and practicing my Arabic with the translator, an Eritrean man a year or two younger than me who was practicing his English, finally I was on the train, and trying to get a bit of actual schoolwork done, when I remembered David and his stoicism and his pain.
How I had had to pull the sutures against injured skin, and hold it taut while trying to find the place to cut. How painful this had been, repeated again and again, twenty times, thirty times. How a patient shouldn’t have to suffer through that. There must be a better way that this is done, maybe lidocaine spray or something. I hadn’t tried to look for it, maybe there had been something like that in the poorly organized pharmacy, that could have eased the pain, if I’d thought of looking.
I had never removed sutures and staples before, and it is a hard thing for a patient to be student’s “first”. It is a hard thing to depend on free rather than professional/institutional health care.
I felt sick about his pain, and sick that I hadn’t tried to do more.

*Names and identifying details are made up to protect privacy, the rest is as true as true can be.

A Blessing to be Around

When are you coming to my church, the patient asked the clinic nurse? The nurse laughed, and said: your church is in Tel Aviv, but I live in a convent in East Jerusalem. “I see that you, my friend, are still trying to convert me,” she said, laughing.
We checked his blood pressure, it was terrible, despite him taking two medications. We talked with him a bit and it became clear that he had been out of his medications for two weeks.
“Why didn’t you come in sooner,” asked the nurse? She sent me to find his medications on the shelves.
As I gave them to him, I told him “ You need to take these, every day, without skipping,” I said.
He said that he would. And then he asked me, “do you want to come my church?
I don’t live here, I live in Beer Sheva, I said, copying the nurse’s tactic. And then I added, “and, I’m Jewish.”
“Jewish? The Jews, how do you say it, they always cause balagan for God!”
Before I could begin to figure out how to respond, the nurse said, in the same friendly gentle tone as before, “why do you say these things? You know Jesus was a Jew.”
So I left the explanations to her, as she described to him how she had reached that belief. She finished by saying that for Jesus, the last supper was a seder, so I told her that for many years my family has been joined by our catholic neighbor for the seder, because we like her a lot, but also because as a Christian she connects deeply to the ritual of the seder.
And we sent the patient on his way, with his medication, and with instructions to come back in a week to have his blood pressure measured, and exacted from him a promise that he would take both of his medications every day.
And I sat there watching how she balanced her concern for, and relationship with, the patient, with standing up for me unhesitatingly, and I knew I was in the company of one of those people who are a blessing to be around.

Things That Seem Clearer Here

Things feel clearer when I’m in Palestine.  Perhaps it’s the space created by PHR volunteers, and the communities that welcome PHR activists and volunteers- there are Israelis that would never come, and Palestinians that would refuse to welcome such a group.  I stumble through my poor Arabic, and people meet me with clumsy Hebrew.  When language fails, the smiles become wider, and brighter to bridge the gap.

What is clear is that the medicine is a small part of what is happening here.  When the doctors introduced themselves, one of the family doctors said in accented but fluent Arabic, that “we are here primarily in solidarity with the people of Saffa, and also to provide whatever medical care we can offer.”  I don’t remember exatly how Salah, the volunteer coordinator, translated solidarity, but I imagine the Hebrew equivalent not as “solidariyut” but as “akhdut.”  We are in this together. Your problems are my problems.  If your children are sick with parasites, if your grandfather has sores on his feet from diabetes, then I don’t get to sleep late on a Shabbat morning yet, because things are not ok.

What is clear is that it is not so hard to live together.  The friendliness radiated off of the Israeli doctors, the Palestinian Israelis who volunteer as translators, the community leaders of Saffa, who welcomed us, forced upon is multiple little cups of delicious coffee, attempted to offer us some brightly colored fake-pineapple juice-drink, and offered us tubs of chicken, rice, and chickpeas after the clinic.

What is clear is that sometimes things get a little better.  Dr. Dani, the pediatrician I was shadowing remarked that when he began volunteering in 2007, a significant number of children were brought in for wetting their beds at night, and today, not a single patient of his was wetting his or her bed. Dr. Dani considered this a sign of decreasing levels of stress and trauma among the children.

Some things are not getting better.  The head of the town council told us how the village had lost some of their lands in ’67 and was losing a lot more to the security fence.  What jumps out very clearly in a pediatric clinic is that this is the children’s future that is being taken away.  Families seem to be getting by, but when Dr. Dani checked their conjunctiva, many of the children had signs of low iron.  We only saw one child with Giardia, but we heard it was common among the children, suggesting a lack of access to safe water sources.  And then there is the lack of economic resources, compounded by the loss of land.  PHR can write referrals for the sort of medical care that they can only get in Israel, and they can generally get permits for the children and their families to enter Israel.  But they will have to pay for the care, up to tens of thousands of dollars, because they are not included in Israel’s health insurance program, and the PA ministry of health will generally not cover such expenses.  One little boy was 6 months old, born with a hole in his heart that was repaired at Tel Hashomer Hospital.  His doctor at Tel Hashomer recommended that he receive a special series of vaccines given to vulnerable infants throughout their first winter to protect them against respiratory infections, but Dr. Dani advised against it- he did not believe it was worth the cost to the family, or that they would be able to get an appointment before winter was over.

What is clear is that I am sick of the Golda Meir quote that never seems to fall out of circulation for long, about how there will be peace when the Arabs learn to love their children more than they hate ours. I can’t stomach this line, especially after seeing the mothers, fathers, uncles, and grandmothers in the clinic today with their children, or after coming in to the pediatrics ward in the morning and seeing parents, Jewish and Arab, sleepless by their children’s beds.  I can’t stomach it after last week, when no one could soothe the fears of a Bedouin father who had lost one baby girl, and whose second daughter was hospitalized with a serious infection.  With antibiotics, the girl recovered, but not before her father drove the entire ward staff crazy demanding to know if she was going to die. By the time the girl was released, the father had not calmed down, but the girl was all bright eyes and smiles and playing patty cake with hands that had been swollen and too painful to touch the week before.

There is something special that happens in the medical world, where I see a microcosm of what could be, that makes me believe that there will be peace when we learn to love their children as much as we love our own.