Each of the more than 1,000 Israelis murdered during the second intifada constitutes an irreparable loss to their loved ones and to the country. But of all the heart-rending personal stories during the past five years, two of the most tragic victims of terror were Dr. David Applebaum, one of the country's leading experts in emergency medicine, and his 21-year-old daughter Naava, who died on September 9, 2003, in Jerusalem's Cafe Hillel during a heart-to-heart chat on the night before her wedding. Instead of answering his beeper and rushing to Shaare Zedek Medical Center's emergency department, which he headed, to treat victims of the blast, the 51-year-old American-born medical specialist and his daughter were casualties.
Dr. Brendon Stewart-Freedman, London-born education director of the post-graduate department of family medicine at the Hebrew University-Hadassah Medical School, recalls that he called Applebaum on September 8, just after David had returned from New York where he lectured on how Shaare Zedek was coping with victims of suicide bombers. "I wanted to suggest to him that we work together to open a southern Jerusalem branch of Terem, the private urgent-care clinic that he founded in the Romema quarter in 1990. He said his daughter was getting married the next day, and that I should call him later the the week." That was the last time he heard his voice.
But although Applebaum's life was cut short, his life work was not. Almost exactly two years after his death, Terem's southern Jerusalem urgent-care station was inaugurated in David and Naava's memory at the Beit Hatayelet building on Rehov Yanovsky 6 in Talpiot, near the promenade and off Derech Hebron, and Stewart-Freedman is its medical director. One of David's sons, Natan, is Terem's director of operations. And Shaare Zedek's $15 million ultramodern new emergency department, which David planned, is being run by his proteg and Terem graduate Dr. Todd Zalut, according to his guidelines.
Life and lifesaving goes on.
Raised in Detroit, educated in Cleveland and an Orthodox Jew with a beard and black kippa, Applebaum rode with Magen David Adom ambulances soon after his aliya in 1981, eventually becoming medical director of MDA's intensive-care ambulance service. He also worked in Shaare Zedek's emergency department and during the last year or so of his life was its director. But he dreamed of opening a private urgent-care outpatient facility modeled after centers that had become popular as an alternative for most hospital emergency-room care in the US.
He, Dr. Joe Djemal (now Terem's administrative director) and four other colleagues invested about $150,000 in renovating MDA's outdated, slow-service first-aid room in the Romema quarter, installing an X-ray machine and a small laboratory. Gradually, it modernized and occupied more space in the building, and added more facilities, such as a sophisticated laboratory and rooms where patients could stay for observation. Open 24 hours a day, seven days a week, the original Terem clinic now treats 100,000 patients annually.
In addition to the new Terem South, which has provided care to more than 5,000 people since its opening last February, Terem also has urgent-care clinics in Modi'in, Ma'aleh Adumim and Beit Shemesh and a family medicine clinic in Jerusalem's Old Katamon quarter. Since 1990, more than 1.5 million patients have been treated at Terem facilities, which remain the only private urgent-care outpatient facilities in the country. All offer experienced specialists many of them English-speaking immigrants in emergency medicine, family and internal medicine, gynecology, pediatrics and other fields. The average time that passes from arrival to discharge is 50 minutes, and the satisfaction rate is over 95 percent. The vast majority of patients go home after their Terem visit, with only about 8 percent needing to be referred to hospital emergency rooms for further examination and treatment.
Some hospital administrators may be rather unenthusiastic about Terem's existence, because they earn about NIS 500 for each emergency-room patient treated, plus more than NIS 1,500 for every one that is hospitalized as an inpatient at the health funds' expense. In contrast, the health funds have to pay Terem only a fraction of what it would cost for emergency-room treatment, and patients' out-of-pocket fees at the urgent care facilities run as low as NIS 50, depending on the insurer; if Kupat Holim Leumit and Clalit Health Services patients are referred to Terem by their own doctors, they don't have to pay the fee at all. But the urgent-care clinics save the health system tens of millions of shekels a year and leave hospital emergency rooms in the cities where Terem exists for the really sick patients. As Applebaum said soon after opening the Romema center, "staff at hospital emergency rooms are always complaining that the majority of patients they see don't belong there."
"Private initiative can provide solutions to problems that the Health Ministry doesn't have to be involved in," says Dr. Michael Dor, director of the ministry's general medicine division who attended Terem South's official inauguration. "The four health funds have responsibility for providing care to members 24 hours a day, but it is very expensive for them to do so in off-hours. They needn't put doctors in all the specialties on duty at night. Instead, they can purchase services from Terem, which has arrangements with all the health funds and is thus more efficient, without the limitations of special labor agreements that exist in the health funds. We'd like to see Terem's model adopted all over the country."
Other organizational clients, besides the health funds, include the Israel Police, private insurance companies, the US consulate, schools and yeshivot.
The trailblazing Romema branch serves an unusual population mix Jews and Arabs from all over the Jerusalem metropolitan area, including many haredim who live in northern Jerusalem. The haredi and Arab populations consist of many large, lower-income families with many children in relatively crowded conditions and often without adequate parental supervision, thus home accidents are most common among them. Since many haredi families are reluctant to go for non-emergency medical care on Shabbat or Jewish holidays, Saturday nights at Terem Romema are usually so busy that a clown was hired to entertain kids during the wait. Although the Romema clinic has been run on weekends and holidays with many non-Jewish doctors and nurses, advances in technology, developed at the Tzomet Institute, have more recently made it possible for observant Jewish staffers to provide care even on these days.
"We realized that relatively few of Romema patients came from southern Jerusalem; many had been needlessly going to hospital emergency rooms because they were closer," says Stewart-Freedman. Terem therefore decided to open the new Talpiot center in facilities designed from scratch by architect Zvika Rubinstein, who planned Shaare Zedek's new emergency department. He spent many hours observing staffers in the Romema branch to note their arm movements and where they moved, and applied what he learned in the Terem South design. For example, the staff room has a corner made of glass so that even when they're having coffee, they can see who's come in for help.
The staff treats the full range of urgent care cases, including light orthopedics, suturing, first aid, and trauma and acute illness. There is also a three-bed observation room for intravenous administration of fluids and antibiotics and patient followup. The center has full laboratory services including complete blood count, biochemistry, throat and urine cultures and troponin tests (to indicate which patients complaining of chest pains have a heart problem rather than indigestion).
A state-of-the-art new computed radiography system eliminates the need to to wait for x-rays to be developed and makes it possible to give each patient a CD record of his x-ray film. This simple and convenient format allows for efficient communication and consultation with other professionals involved in continuation of care. Ultrasound services are also available during most opening hours to determine whether internal damage was done after trauma, to rule out testicular or ovarian torsion, check on fetal movements in pregnant women and rule out an extra-uterine pregnancy.
Unlike the round-the-clock Romema facility, Terem South operates so far from 6 p.m. to midnight on weekdays, Fridays from 10 a.m. until two hours before Shabbat, and Saturday nights one hour after Shabbat until midnight. At these times most health-fund clinics are closed. Brendon-Stewart says that it is likely that the Talpiot branch will expand its hours, even eventually becoming 24/7, depending on how much demand there is for its services. It isn't yet making a profit, but "we are exactly on target according to our expectations."
Some 30 patients arrive on an average evening. The majority of the population of nearby Talpiot, Ramat Rahel, Baka, Abu Tor, Har Homa and Gilo are secular Jews with fewer children and higher educational and economic levels, thus they have fewer home accidents than residents of northern Jerusalem. Some patients who go to Terem South previously used the Romema clinic, but most are completely new customers, says Stewart-Freedman. "We expect to treat some 9,000 patients a year here during the evening, Friday morning and Saturday night hours."
Family physicians often feel "left out" when their patients go to hospital or are treated in outpatient facilities, he continues. "Some of them weren't even informed that they didn't feel well and needed urgent care." Thus Terem South staffers contact family physicians and general practitioners before discharge to keep them informed and consult on a patient's medical history if necessary. Medical lectures and courses for community doctors are also being offered.
A smiling David and Naava look down from their photographs on the wall of the new Terem clinic. They, who are greatly missed, would undoubtedly have been pleased with the healing it provides and the way it functions.