Coronavirus is overwhelming Israel's hospitals – here's how

HEALTH AFFAIRS: Hospitals around the country raise red flags and warn that if the high infection rate continues, patients will not get the care they need.

DOCTORS IN Jerusalem’s Herzog Hospital coronavirus ward, which recently opened due to overcrowding in Hadassah and Shaare Zedek medical centers. (photo credit: Courtesy)
DOCTORS IN Jerusalem’s Herzog Hospital coronavirus ward, which recently opened due to overcrowding in Hadassah and Shaare Zedek medical centers.
(photo credit: Courtesy)
 The coronavirus pandemic has left Israel with empty storefronts and vacant hotel rooms. But the country’s internal medicine, intensive care and emergency units are bustling with sick patients and – without drastic steps – are likely to burst at the seams come winter, health experts said.
“There just won’t be enough beds,” Dr. Yehezkel Caine, director-general of Jerusalem’s Herzog Hospital, told The Jerusalem Post.
Nearly 4,000 new patients were diagnosed with the novel virus on Wednesday, the Health Ministry reported. Almost 1,000 of the total sick were being treated in hospitals.
Caine described a scene come December where emergency rooms would be operating out of hotels or in tents in hospital parking lots. When that happens, “I am sure patients are not going to get the treatment they need. It is a difficult thing to say, but at the end of the day, it is a zero-sum game. Doctors and nurses can only do so much, and they are already overextended. It could be catastrophic.”
Caine spoke to the Post a few weeks after the hospital opened a coronavirus ward to help support the city’s sick patients, which were overcrowding Hadassah and Shaare Zedek medical centers. The unit opened and welcomed its first 36 patients. In five days, that number reached 50. Currently, there are nearly 70 patients in the unit, lined up on gurney-like beds with only thin dividers between them.
Jerusalem has the largest elderly population in the country – 80,000 individuals over the age of 65 out of a population of around one million people, Caine said. Of those above the age of 85, more than 50% of them are Holocaust survivors.
The capital is also home to a large population of haredim (ultra-Orthodox). Coronavirus commissioner Prof. Ronni Gamzu recently said they make up 22% of all virus cases.
Herzog, which was founded in 1894 as a psychiatric hospital in the Old City, is now located in the capital’s Givat Shaul neighborhood. It is best known for its treatment of ventilated patients – close to 200 at a time – ranging in age from seniors to children.
Each winter, Caine said, the emergency room is overcrowded with patients suffering from respiratory infections and seasonal flu. More times than not, some of these patients are treated in corridors or cafeterias. However, he warned that unlike in most years when the patients who are stuffed in the ER are not dangerous to one another, “here we have a serious problem because many of the patients will be coronavirus patients or will have symptoms of coronavirus, so we will have to keep them separate because we don’t know.
“Any patients admitted off the street will have to be isolated until we get their corona test results, and only then can they be admitted into the regular hospital,” Caine continued. “So, we are going to have a big backlog in those isolation areas. How are we going to man them?”
He said that his hospital is funded almost 100% by philanthropy, and the government has been slow to commit to how much it is going to reimburse the hospitals for treating coronavirus patients. The coronavirus unit cannibalized staff from other departments, forcing Herzog to close down its acute geriatric and geriatric rehabilitation departments.
To help fill the void, Caine said, his hospital is trying to recruit more staff.
THE HEALTH and Finance ministries committed to paying for some 2,000 more nurses and 400 doctors immediately through June to help handle the overload. However, Caine said there is a dire shortage of staff for hire in the country and especially in the Jerusalem area.
He explained that the staff that is available tends to be in Gush Dan, and it is “difficult to entice them” to move to the area with its high cost of living and often lower salaries.
Arnon Afek, deputy director-general of Sheba Medical Center, Tel Hashomer, said there is a deficit of nurses across the whole country.
As the Post has reported previously, Israel is woefully understaffed when it comes to all medical professionals, the statistics show, but especially when it comes to nurses. Israel has nearly the lowest number of nurses per capita compared with other OECD countries and nearly the lowest number of nursing school graduates.
“When we speak about an influx of new nurses, they have to pass the national boards, and that will only happen at the beginning of October, so we do not have people available to hire now,” Afek said. “Physicians have to wait to finish their residencies – this all takes time.”
He said that “positions are useless if you don’t have the individuals to fill them. There is a countrywide shortage because of a lack of long-term planning.”
Coronavirus units require more staff than average departments because personnel are required to wear full personal protective suits that can be sweltering hot and difficult to breathe in. Caine said his staff works two hours in a coronavirus unit and then two off in 12-hours shifts to make it bearable.
Moreover, the cost of the personal protective equipment is extensive. For maximum protection, the suits need to be taken off and cleaned or even discarded each time a doctor, nurse or aide enters and exits the department – even if only for 15 minutes.
Caine said the hospital, if it could recruit enough staff, has the opportunity to open a second coronavirus unit, but he is trying to put it off because it is a “major undertaking that has implications on workflow, supplies and access... It is very expensive, and the minute we start doing it, we have to double everything.”
IN THE NORTHERN part of the country, hospital heads paint an equally frightening picture.
Prof. Masad Barhoum, director-general of Galilee Medical Center in Nahariya, said his hospital is seeing a gradual increase in the number of patients in general and in the number of moderate and serious patients in particular.
“This is very challenging data for us and it requires us to rethink when it comes to manpower,” Barhoum told the Post. “This is because manpower skilled in treating critically ill patients is extremely limited.”
He said that the hospital recently trained a large cohort of staff to help treat moderate and serious patients, including those who are intubated, but these are not intensive care teams, which makes them less than ideal for such a serious influx of sick people.
“The rope is being stretched thin,” he said. “There is no chance I can continue to treat more patients if I fill all 35 beds we have in the new ward we opened,” he said, noting how his hospital recently expanded again to accommodate the latest spike in coronavirus patients.
On Thursday, the hospital reported 59 patients, among them 25 in serious condition.
Prof. Fahd Hakim, director of EMMS Nazareth Hospital, expressed similar sentiments.
“We are collapsing,” he said, “and I do not use that word easily. Northern hospitals do not need the daily infection data to know this – they feel it in their wards.”
Hakim said the current numbers show with certainty that the way Israel is currently dealing with the virus “simply does not work.” He said the whole country is red, and “there is no choice but to take more direct measures... to stop the spread of the virus – especially during the approaching holiday season.
“This must happen now,” he stressed. “It is not possible to just talk about the personal responsibility of the citizens, when we have thousands of verified patients per day!”
Afek described the increase in the number of people who test positive for coronavirus as “alarming” and said that although the majority are asymptomatic, there is a constant incremental increase in severely sick patients, which is “quite worrisome.”
A coronavirus report published earlier this month by Hebrew University researchers showed that the rate of infection and the mortality rate are expected to climb through the end of September and recommended “vigorous action.”
“The stabilization period” has ended, they warned. “An increase in morbidity is expected.”
The report explained that until this month, the number of hospitalized serious patients was balanced by the number who died and the number who recovered from coronavirus. They said that the rate of infection is rising in certain locations and that the coefficient (R) is at more than one, meaning that each infected person will infect more than one other person. As such, “the current balance in the number of serious patients is expected to be broken.”
The researchers did note that the rapid increase in serious patients could be delayed 10 to 12 days by using effective preventive measures and restrictions, such as more effectively limiting gatherings. They showed a direct correlation between limiting gatherings and lowering the rate of infection.
HOWEVER, PEOPLE are not following directives.
Barhoum said that earlier this week he witnessed a wedding with hundreds of participants in one of the villages near Nahariya.
“I see it as a speeding truck and ask myself how the damage can be minimized,” he said. “People are not afraid... They say to themselves, ‘It will not happen to me.’”
Barhoum said people who are asymptomatic leave their homes, ignoring the guidelines. They do not understand that they may infect their parents or grandparents. “I am very upset.”
Afek said that Gamzu’s traffic light plan may have come too late to be effective; the government put off voting on the outline for three weeks and, when it did ultimately pass, it fought Gamzu on how to handle red zones. Maximum restrictions were not implemented, allowing the virus to spread.
At the time of this writing, the coronavirus cabinet was debating what steps would be taken over the High Holy Days. Afek said that regardless of the outcome of Thursday’s meeting, if the country ultimately does need to have a total lockdown – something that did not seem likely Thursday afternoon – the time to do it would be over the holidays.
“A general lockdown has a lot of detrimental effects on the people and the economy,” he said. “If you are looking for a period that would have the least problematic effect, it is the holidays.”
According to the Finance Ministry, a general closure over a “holiday week” would cost the country NIS 4 billion, and a closure on a full week NIS 5b. to NIS 6b.
“I would have enacted a closure yesterday,” said Dr. Rivka Abulafia-Lapid, a senior lecturer on virology at the Hebrew University.
She told the Post that with 3,500 new patients a day and the doubling rate (how long it takes for the number of coronavirus cases, hospitalizations, etc. to double) reducing all the time, “it is going to get worse and worse.”
She said that anything short of a lockdown means Israel is “in denial. I am really worried about us.”
She lashed out at a group of 90 doctors who earlier this week launched a campaign to convince the government to shift course in its handling of the coronavirus crisis, and adopt a model similar to Sweden’s: minimal restrictions to allow the population to develop herd immunity.
“I don’t agree with these scientists and I don’t understand why they are saying this,” Abulafia-Lapid said, noting such false assertions could put Israelis at further risk.
The doctors wrote in a letter to the prime minister: “Given the large amount of information piling up about the low danger of mortality among the healthy population, and given the lack of certainty about the lipid efficacy and safety of a vaccine being developed soon, and in light of the research done until now, it’s clear that the best way to get out of the crisis quickly with a minimum of death (and also damage to health and the economy) needs to center on developing deep immunity by preventing the elderly population at risk from being infected.”
BEN-GURION University of the Negev Prof. Mark Last predicted in August that the coronavirus infection rate in Israel would start to decline by the end of September because of a combination of herd immunity and social distancing.
“There are several indications that when the entire population is susceptible – meaning, there is no immunity at all – but the population observes social distancing, then the reproduction number (R) is somewhere between 1.1 and 1.2 – closer to 1.2,” Last explained to the Post. The R number is how many people one infected person will infect.
He noted that from serological tests, Israel knows that nine to 10 times more people have been infected with the virus than the number of confirmed cases, which is around 112,000.
“We already have more than one million people with antibodies – with immunity,” he said.
According to Last, when about a sixth of the population becomes immune and people observe social distancing, then the reproduction rate will drop below 1 and therefore the number of infected people per day will also decline.
“We need to get about 1.5 million Israelis infected, which means 140,000 to 150,000 diagnosed cases,” the professor said. “That should take only a few more weeks.”
Two weeks from his prediction, however, the number of coronavirus patients was climbing and not declining. And in the meantime, Afek said, the patient load on the staff at the country’s hospitals is huge.
“The health system has raised a red flag,” Gamzu said Thursday.
“There is an enormous feeling among the medical staff that there are population groups that feel a sense of entitlement to do what they want to do without consideration on the impact of public health,” Caine said. “They are holding weddings, congregating – and it is not just haredim and Arabs, it is the people at demonstrations, people crowding there together not wearing masks, not social distancing.”
Caine described a patient who has been in the hospital since Passover, after his family held a large Seder against Health Ministry directives. One of the youngsters had coronavirus and he contracted it.
“He is probably going to recover after a lot of effort,” Caine said. “The coronavirus has blown over, but he is left with respiratory problems – and there are many, many cases like his.”
He continued: “You have a right to do what you want, so long as you are willing to pay the consequences.” •