Israel’s health system is simply not equipped to cope with burns victims because the state has neglected the situation for decades.
By JUDY SIEGEL-ITZKOVICH
It’s unfortunate that most victims of serious burns are poor, says MK Prof. Arieh Eldad with bitterness.“If burns happened mostly to rich people, the government would take urgent measures to ensure that there are high-level, dedicated burns units in at least three hospitals around the country.”Eldad, who was head of the burns unit and plastic surgery department at Jerusalem’s Hadassah University Medical Center before leaving to serve as the Israel Defense Forces chief medical officer in 1997, was elected to the Knesset in 2006.Although he remains immersed in politics and lawmaking as a representative of the National Union Party and says he remains in parliament solely “to prevent the establishment of a Palestinian state,” he continues to attend burns conferences and read medical journals in the field. The 60-year-old Eldad remains one of the country’s leading experts in burns treatment.In an interview initiated by The Jerusalem Post after the Carmel Forest catastrophe – which resulted in the death of all four burn victims from the Israel Police, Prison Service and Fire Service who survived the inferno – Eldad says the lack of adequate burns treatment facilities is no less dangerous than the dearth of firefighting equipment and trained personnel that was revealed during the huge fire. The Israel Railways fire in the Sharon region not long after – which fortunately resulted in only lightly injured victims of smoke inhalation – induced the MK to think about how the medical system could have coped with many burns victims.Eldad says he has “given up hope” on the ministry which, over decades, has been criticized by state comptroller reports and medical specialists for neglecting burns patients – and yet nothing has been done about it.The main problem, he insists, is that health officials remain silent and inactive because they know the Treasury will refuse their requests for special funding.ELDAD SAYS: “When there is any event with numerous burn victims, the Health Ministry directorgeneral has to call all the hospitals in desperation for a place to treat them.” He claims that Israeli burns victims have half the chance for survival, compared to those in the US or Europe because none of the centers that take care of them – intensive care units and plastic surgery departments that also serve other kinds of patients – has all the facilities and highly trained manpower that they need.Dedicated burns units abroad have their own intensive care units, with on-site facilities to wash the patients, as they are constantly in danger of serious infections. A surgical theater and their own anesthesiologists to relieve the horrific pain, as well as rehabilitation services for survivors, are also needed on site.“When I heard of the forest fire victims, with burns over 80 percent of their bodies, I knew in advance that they had no chance of survival.”In the case of the Carmel forest fire, the four were rushed to Haifa’s Rambam Medical Center, which doesn’t have a dedicated unit but fought a losing battle to save them. Sheba Medical Center at Tel Hashomer has a burns unit, but Eldad maintains that it needs more staff, including a full-time anesthesiologist and equipment that are available in the best centers in the US, France, the United Kingdom and other countries. The MK says it isn’t economically feasible for hospitals to keep a dedicated burns unit going all the time without subsidy by the state, as the number of cases is relatively small.IN ADDITION, hospitals receive very inadequate financial compensation for treating each seriously burned patient – just NIS 120,000, when the actual cost is an average of NIS 400,000 – even without taking skin grafts into consideration. Thus it is not surprising that they are unwilling to set up dedicated burns units at their own expense, since they would be run at a loss. If the Health Ministry were to greatly increase the diagnosis-related group (DRG) rates for burn treatment, the hospitals would be overjoyed to upgrade their units as urgently needed, says Eldad, who recommends that the DRG be tripled.Eldad notes that Israel has relatively few burns cases compared to other countries. “No system can be at maximum readiness for burns all the time because of economic limitations. But there is the potential for many times the ordinary number of burn injuries in the event of war at the front. In the Six Day War, the rate of serious burns injuries among soldiers was just 5%, but it doubled in the Yom Kippur War and was higher during subsequent wars.And if missiles hit civilian areas and sensitive facilities containing inflammable materials, that could cause serious injuries in the event of a direct hit, he explains.“In war, we can expect 20 times the regular number of casualties.” Even in the event of an earthquake, fires would not be common because of the way heating gas is stored and distributed. Thus he believes there is a need for five or six dedicated burns unit around Israel, and not only three – “but we must start somewhere.”In an major catastrophe, if a unit has a few doctors and nurses who are experts in burns treatment, they can teach others on the spot. But we need a kernel of burns expects, as it takes a nurse months and a doctor years to learn it. They need the ‘eye’ for it and experience, and not just to follow protocols.”The problem, he says sadly, has gone on for many, many years, In 1978, the Supreme Hospitalization Committee comprised of Health Ministry, health funds and IDF representatives, recommended and gave permission for the establishment of five dedicated burns units. The committee stipulated that all hospitals must have advanced trauma facilities. In 1993, the ministry “decided” to establish dedicated units, one for children, in five hospitals, but took no action. Only at Sheba Medical Center is there a good burns unit, even though it needs more to be on the highest level, according to Eldad, who was not replaced when he left Hadassah in 1997.Prof. Shlomo Mor-Yosef, director-general of the Hadassah Medical Organization, says plastic surgery and general intensive care units treat serious burns patients today. The Ein Kerem hospital still bears the sign of the Kobo Burns Unit that Eldad founded, but which has been empty since then, except for esthetic plastic surgery. If the ministry offered better financial incentives for fully fledged burns units, says Mor- Yosef, “we would consider [installing one] at Hadassah. There will be room for one in the new hospitalization tower we are building, but it can be established only if there is funding.”PROF. SHMUEL SHAPIRA, director of the military track of the Hebrew University Hadassah Medical School, says “nothing has moved in Israel in treating burns victims, especially since a scathing, seven-page section was published in the State Comptroller’s 2000 report.Unfortunately, the problem is not just money but even more so of manpower. Treating burns victims is very demanding, more than working in neonatal intensive care. It requires endless devotion. Almost nobody wants to specialize in plastic surgery to treat burns, but rather to enlarge or reduce the size of breasts or straighten noses.Prof. Eldad is devoted to the subject, but he is not here; he is in the Knesset. A mega-terror event is defined as one involving an average of 500 wounded. A mega-terror event that involves burns victims means 20 or these have serious burns,” says Shapira. “If the Israel Prison Service bus in the Carmel had 20 burns victims, the health system would have been in big trouble. I don’t even want to think of what would happen in a war. Israel lacks a nucleus of highly trained professionals who could serve as the basis for rapid expansion in an emergency, and I strongly recommend not depending on foreign experts from Turkey, Greece or Bulgaria,” he adds.In normal times, the majority of serious burns patients are young children from large haredi families who are burnt from too-hot baths, Shabbat samovars and hotplates, overturned pans or Hanukka candles; and Beduin children, Palestinians and elder Israelis hurt by fires that start from primitive kerosene stoves.“The problem has been raised in the Knesset, but nothing was done,” says Eldad. “Most Knesset committees – except for the Finance Committee – just talk .”PROF. RAFAEL BEYAR, director-general of Haifa’s Rambam Medical Center and one of the world’s leading interventional cardiologists, says “dedicated burns units are an absolute necessity and must be well financed. The moment there is money, we will be able to find burns unit teams with the necessary knowhow in a short time.” Rambam, he adds, would need at least $500,000 for equipment and more nurses and doctors. “We receive patients and share facilities with other departments, but lose financially on every patient we treat,” says Beyar. “There are also people willing to study the specialty if there were dedicated burns units where they could work.”Dr. Josef Haik heads Sheba’s burns unit, which the hospital has for some time been trying to get recognized and funded as a regional or national burns center. He says that with additional money and recognition, its planned dedicated burns unit would include intensive care treatment for six burn victims simultaneously and offer absolute isolation against bacteria and viruses using the most technologically-advanced construction design, air and water purification and sanitation systems. A multidisciplinary team of psychiatrists, infectious disease specialists, occupational therapists, physiotherapists, dietitians and social workers dedicated to burn treatment would also staff the center.Haik envisions it as conducting advanced research and development in tissue engineering and production and in tissue immunity and conducting mass trauma and emergency preparedness training for all Israeli burn units – along with burns prevention education in schools and community centers. The total cost for upgrading would be over $3 million.HAIK, A plastic surgeon and expert in reconstructive burn injuries and critical care, says he trained at the worldfamous Firefighters Burn and Intensive Care Unit at the Alberta University Hospital in Edmonton, Canada. He is also an instructor in plastic surgery and burns at Tel Aviv University’s Sackler School of Medicine and has led Israeli humanitarian medical delegations to Indonesia, Kazakhstan, Kenya, Peru, Romania and the Congo. He is also the chairman of the burn-prevention committee of the Israel Council of Trauma.His unit treats about 40% of all serious Israeli burns patients – about 200 a year, with most of the others admitted by Beersheba’s Soroka University Medical Center, where most victims are Beduin children. About a fifth of Sheba’s burns patients are Palestinians from the territories who have no facilities to treat them.“At present,” he says, “we have no dedicated operating room or anesthesiologist, but do have an intensive care unit and burns nurse of our own, air mattresses for patients and a place to wash them. Haik notes that he is worried about the country’s sole skin bank at Hadassah University Medical Center, because its director is retiring, and it is not certain who will replace her. He thinks another skin bank – which freezes and stores skin taken with family permission from deceased loved ones – should be established. But he says fresh skin is even better than frozen. He also uses artificial skin (Integra) in small pieces for small burns, but this can be transplanted to burns victims only within 72 hours of their injuries and needs constant supervision by experienced nurses.If the burns victims from the Carmel fire had survived, they would have occupied beds for six months in Rambam’s general intensive care unit, which has just 12 beds. They would have needed a dedicated unit that would not come at the expense of the general facility, Haik states.“The Health and Finance Ministries just don’t understand the needs of burn units. If they refuse to act, perhaps Prime Minister Binyamin Netanyahu, who is formally health minister, should announce that the country’s health system is not interested in treating victims with more than half of their skin burnt,” he says cynically.“In the US, private health maintenance organizations pay all costs, as in Canada, which has a national health insurance system like ours. “I remember a patient in Canada whose treatment costs were over $1 million!”
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