I thought I would write a quick note as its been one year since Marty and I had our experience in Palestine. What a great experience there for both of us and I hope we helped the Palestinians and our friends there are well. I reread our blogs and really not too bad for amateurs and relived parts, and I would like to go back to both Palestine and Malawi. (see my Malawi blog) I am in Eau Claire where I now do work as a vascular and general surgeon for a great group called Evergreen Surgical at Sacred Heart very reminisenct of Binder, Alden, Mattingly, and Asplund before SA changed. I learned it is very hard to get surgery out of my system and truly retire because I have spent so much of my life getting as good as I can possibly be at it and I truly enjoy it. I also learned it is so deeply ingrained in me I can be away from surgery for a year and do a 2 1/2 hour fem to peroneal bypass with vein that looks perfect and will last. In any event I doubt we have any readers left. If I make it back to Palestine or Malawi I will put out a notice and start up my blog again. In the meantime hope all is well.
I discussed our goals of going to Palestine in our initial blog. We feel this has been a great trip and we have accomplished our goals. We set out to help individual Palestinians with their medical care, share our knowledge with providers there (this was a two-way street), for father and son to work together for maybe the first and last time, learn about the Palestinian people and Islam, and finally gain insight into the Israel-Palestine conflict.
I also think it has been of value knowing we have some friends following us (over 1200 views in 6 countries) and maybe passing on some of our new insight into the plight of the Palestinians. It is hard to live with them for two weeks and not empathize with their cause. This hotbed will affect all of us, that I am sure. The more we can learn about the middle east the better.
I would like to give a short primer (very condensed version) on my current understanding of the situation of specifically the Israeli-Palestinian conflict. I would first start with a disclaimer this is not comprehensive and I am not even close to an expert.
One always has to start with history. Zionism is the concept of a Jewish homeland that Jews all over the world can move to and be safe. There was some writing to make it somewhere else than Palestine. This began in the 1850’s and then clearly defined by an author named Theodor Herzl in 1896. He is very honored in Israel. As we know from biblical history Abraham first settled in this area, moving from I think Ur in current Iraq about 1700 BC. Because of drought he moved to Egypt where the Jews were eventually enslaved and centuries later Moses led them back to the “promised land”. First Nebuchadnezzar then the Romans dispersed the Jewish people to Europe, Asia, and North Africa. After centuries of persecution that only got worse in 19th century Europe and Russian programs (think Fiddler on the Roof) Zionism was born. At first there was a trickle of emigration to this area with buying of land in the late 1800’s and early 1900’s. This became a torrent with the worsening persecution in Europe leading up to WWII and eventually the horrors of the holocaust. The Jewish people clearly needed a place to call home and live in peace. Unfortunately there was already someone living there. Britain which controlled most of the middle east at this time had made promises through various documents to both the Jews and Arabs. It started to get quite violent as Britain, Jews, Muslims, fought and WWII raged. Post WWII the newly formed United Nations gave the Jews the right to have their own land which lead to the first Israeli-Arab war. This was a fight by Israel for their existence and they won and annexed much of what was Palestine, forcing many of the Palestinians off their land to make room for the Zionists. Israel was born. Since then more territory was won in the 1967 war (West Bank and Gaza where we were), and in 1973 (Golan). The Palestinians fought back with terror, bombing cafe’s, public buses, weddings with suicide bombers and lobbing missiles into residential areas from Gaza, West Bank and Lebanon. Israel reacted. This lead to the state they are in now basically a lock down.
Unfortunately Zionism continues and all talk of peace has broken down, and new internationally illegal settlements are being built every year in the West Bank and Golan and pushing the Palestinians into ever smaller areas with more and more restrictions. The politics in Israel is very complicated as well with ultra orthodox jews to secular nationalist Zionists that believe all of the current West Bank, Golan, and Gaza is part of Gods “promised land” and want to annex it into Israel. Israel is protecting its citizens but when an incident happens they react very violently and it’s always the innocent that suffer. The last war in 2014 took the life of 2100 people in Gaza, mostly civilians, of which 495 were children and 250 women. Most of the survivors were treated at the hospital we were at in Gaza.
The USA role in the middle east has been nothing short of disastrous. Supporting many ruthless dictators if they were anti-Soviet,(we helped Saddam Hussein, Sadat and Mubarak in Egypt, the Shaw), invading Iraq, financial aid (over 237 billion alone to Israel since 1948), blocking enforcing United Nation resolutions against Israel, and supplying weapons to Israel and other Arab states. The tear gas canisters used to disperse the Arab spring protestors actually said Made in USA on them and our weapons were what was used on the Gazans. Our government is not popular, a stream of broken promises. We have supported Israel in all confrontations except for Eisenhower once in 1956 Suez Canal war.
The conflict between the Palestinians and Israeli is not really a religious war although god is invoked often. It is war over land. It is Israel pushing the Palestinians off the land they have been living on for centuries and treating them as criminals. It is like our manifest destiny against our natives and the current situation President Carter (and I agree) likens to Apartheid in South Africa.
So what is the answer? One state, two states, keep the current situation(not sustainable)? I really don’t know but it is stalemated at present as Israel has the upper hand and is getting more right-winged. It is getting more and more dangerous everywhere in the middle east as religion is becoming radicalized and important in politics in all the Muslim world and in Israel, and if you think about it even in the US. I do think the Palestinians will need outside help from the United Nations and not individual meddling by individual countries but as long as the US, France, Britain, Russia, and China has veto power over all UN sanctions that body will remain impotent.
And this is only one flash point in the middle east. Think Syria and ISIS, and all the Arab spring nations.
The least we can do is hold our government accountable for its actions. Get informed. Interestingly the candidate speaking out the most against Israel’s actions and against the concept of Zionism is Bernie Sanders who is Jewish.
Anyway it is nice to be home. We are still jet lagged.
Spring is here. Wood ducks on my pond. Cacophony of peepers to put me to sleep. Thank you for reading and sharing our experience. I will check from time to time for any feedback but this will be it for my brief writing career. Peace.
We are nearing the end of our trip therefore the end of our blog. After being home a bit and reflecting we think we will send a summary and maybe some opinions regarding the Israeli-Palestinian conflict that seems to have no solution. It pervades all conversation and thought here. When we are at the airport they are so nice to us until they find out we have been in Gaza and West Bank.
Ask surgeon how things are going and he/she will say too busy or not busy enough. Yesterday Marty and Mark had two major surgeries planed, complicated lower extremity revascularization for black toes(gangrene). We had been having 10 hour days of surgery so we went to bed early and were well rested and ready to go. But both cases were cancelled with the patient on the operating room table by the anesthesiologist for rapid atrial fibrillation(he said 160), without telling us, he just wheeled the patient out. The chart and our fingers said the pulse was 80-90 and there are drugs to control the rate. Apparently the counting of the anesthesiologist is the official count in Gaza and there was no recourse. So next visit I am looking for an anesthesiologist, to join the team and you can tell him they rule here.
We still managed to keep busy seeing consults and discussing cases oh and drinking a fair amount of thick black coffee and tea. It also allowed us to make contact with several other organizations including meeting with the International Red Cross.
We then went to a restaurant with Suhail overlooking the Mediterranean Sea that may have been the best seafood I have ever had. The Israelis recently (after the November 2014 war) changed the distance Palestinians can go out to fish from 6 mi to 10 mi. Calamari, shrimp, and fish.
Then back to hotel and the usual, Marty beating Mark in yet another game of cribbage. He is 5-0.
Today is a different story. The long sojourn back home started. I am currently at the airport waiting for our redeye to the good ol’ USA. We got up early and went to see our patients and the pulse was great. Then the necessary evil of going through the WALL at the only checkpoint in and out of Gaza. It was like a rat maze of Plexiglas, cement , and steel doors. It is harder to get back to Israel than leave. It went like this. First there is a series of just passport checks on the Palestinian side. Then its the long 500 meter at least walk through the steel cage to the doors. The doors are several thick steel doors that open only when activated by someone, and we must go through one at a time. Next we have to go though a plexiglass door into a plexiglass cage where we sit for a little bit and then exit. Green lights tell you when to enter and exit. There is an unseen voice that will “help” you, “a little right” of how to traverse it. Next are the metal pipe revolving doors that lead to the luggage search then through an xray machine and airport type screen. Finally another plexiglass cage where an official questions you and then to a waiting taxi. I’m not making this up.
Since our flight doesn’t leave until 11 pm we decided to do something. Our vote was the beach. But we were advised to see the main sights, Jerusalem and Bethlehem. We went to the Old Jerusalem (East Jerusalem) probably the most religious and controversial site in the world. Once is enough. It is extremely important to all three monotheistic Abrahamic religions. For the Muslims its the dome of the rock which we couldn’t see as its only for muslims today, for the Jews the western wall which is the remaining wall of the second Solomons temple where brave IDF forces were massacred centuries ago, and the church of th holy sepulchre for Christians. Marty said this is where Jesus was buried but I thought he rose to heaven. It was built-in the 4th century. The spectacle was amazing with the most pious of all these faiths kissing various stones or prostrating, amongst tourists from Mississippi and Amsterdam, the ever-present Israeli military with their automatic weapons, ant then the street vendors selling you whatever you wanted, silver orthodox crosses, western crosses, jewish stars, and muslim moon. East Jerusalem is a functioning city as well with the most narrow of cobblestone streets and very very old buildings. But too many people. I believe it is considered part of Palestine but clearly in complete control by Israel.
We are now at the airport settling in to the time hop. The PCRF has already asked us back so I have been taking notes as to a return trip and supplies, including an anesthesiologist, ask around, and a new assistant as Marty will be in the throes of his internship, as well as a supply of instruments like US, castros, geralds. One cannot feel for the Palestinians but it is a complicated story that maybe in a few days I can shed a little light. Is there a solution? I think it behooves all Americans to become informed as to what is going on in the middle east as this cauldron of people, who are basically like us, is a potential for a devastating war. And I must tell you they are all aghast here that we would even consider electing a narcissist like Donald Trump. (Not a paid political ad)
We have to board soon
By far the most interesting experience has been the crossing between Israel and Gaza. Along with pushing the boundaries in, Gaza.
After leaving the West Bank we had to cross back into Israel to get to Gaza. As we came down out of the mountains onto the coastal plains it was basically like we stepped into suburban North American. The contrast between Israel and Gaza is stark, from the greenery of Israel with running paths, bicycles, modern buildings, beautiful roads, palm trees, and orange groves to the refugee camps, bombed out buildings, dirt, and people idle everywhere with unemployment at 40% in Gaza.
The border crossing between Israel and Gaza can be seen in the picture above. This is the wall between Israel and Gaza. There are no roads in or out, only one check point in all of Gaza that you walk through. The walk is about 500 meters in this caged tunnel and it is guarded by the Israelis. No Palestine is allowed out unless they obtain a permit, and only a handful of people receive these. There are about 1.8million people in 1/10th the size of Rhode Island.
The hospital we are working at is called Al-Shifa Hospital, it is a government hospital. They have a very good vascular department here. We along with 7 or so vascular surgeons went through a few of the difficult cases. There ended up being two patients with ischemic feet, with digit amputations and necrosis. Neither of these patients had adequate blood flow to the feet. In order to salvage the limb and save this patients foot we would need to do distal bypass from the knee to the artery on the top of the foot.
The benefit of doing this operation in the frontier hospital in Gaza is three-fold. First it helps patients get medical care that they wouldn’t have gotten otherwise, in this case the patients would have ~0% of saving the foot without surgery. Second we will be able to teach the attending doctors how to do it. And third, they have never used certain techniques here, intraoperative angiography (the same one we wanted to do in the previous post). During this case today was the first time that this hospital and I belive all of Gaza used angiography during the surgery! We map out the arteries and found an open blood vessel in the foot to attach the distal end of the venous graph.
The operation today went well, but the struggle is real. Mark says “you just can’t understand how hard it is to operative under these (less than ideal) conditions.” It was a hard day. So Mark is exhausted now, but he did very well. The patient is doing well and has a good pulse in his foot! I think next time we will bring some of our own instruments.
Tomorrow we do it again!
The surgeries, a vein stripping and femoral endarterectomy, went well at Rafidi hospital this morning as we said good-bye to Rafidi Hospital and this ancient city. We had many new friends of which only a few we could both pronounce much less remember their names. As we left we were awarded a plaque and certificate of service. It was quite rewarding. Marty said it well, everything looks old here. Even the countryside where every hill has staircased terraces for farming and olive trees supported by ancient rocks.
We have to acknowledge our two devoted contacts here in Nablus. Hanna and Sawsan were absolutely perfect hosts, and made sure every logistic went perfect. Cab rides, breakfast, lunch, dinner, clinics, operating rooms, and coffee breaks. They were with us every minute during the day. They are so pleasant and dedicated to the people of Palestine. As another example of how the lives of everyday Palestinians is interrupted Sawsan lives 9 minutes away getting to Nablus to be with us in the morning but has to go a different route home due to Israeli checkpoints and takes her over an hour. Thank you Hanna and Sawsan.
We then traveled to Ramallah which is just north of Jerusalem. The trip was through winding roads and notable for he ancient country side, the several checkpoints we are getting used to, and a sheep traffic jam.
Ramallah is the most modern and cosmopolitan city in Palestine. It has a large Christian population (no correlation). It has more modern buildings, is the center for the Palestine Authority, and the home base of many NGO’s including ours the PCRF. We met the Steve Sosebee the founder and CEO of PCRF along with his 9 year old daughter. Steve founded PRCF over 20 years ago with his wife who unfortunately passed away from leukemia several years ago. She was Palestinian who he met as a college student when he studied here. Steve is from Kent, Ohio. Steve told us he came to Palestine because he grew up very politically active because of the attack of the National Guard of the Vietnam protestors at Kent State where I believe 4 students were killed in 1970. In any event PRCF and the Palestinian cause has become his life work and he has helped so many people here and I am sure will form many years to come. His travel has been restricted severely by the Israelis despite he daughter being a Palestinian citizen. PRCF is entirely funded on private donations so again I encourage you to go to their website and give to a worthy cause. Currently Steve is funding and creating multiple important missions and facilities, but the most impressive is building Gaza’s only pediatric cancer department costing 10 million dollars. And he can’t even visit it to supervise and watch his vision take shape. Such is life under an outside authoritarian state.
Otherwise it was a relatively down day. We leave at 7:30 to leave for Gaza Strip to work at a hospital only a stones throw from the Egyptian border, and will be staying at a dormitory attached. We are not sure what we will be doing but this old surgeon hopes it’s not quite as busy. We did 18 surgeries in 6 days of which one lasted 10 hours(it wasn’t suppose to). If you look at a map you will realize that despite Gaza being part of Palestine, Israel separates the two areas so will be going around Jerusalem, through two major border checkpoints to get to Gaza. No cars are allowed in into Gaza so we will have to walk across the border and pick a new taxi on the other side. We anticipate a unique day tomorrow.
As we describe our days here please note a consistent theme of complete control of travel between and outside of the Palestinian cities. Within the country side and even on the outskirts of Nablus there are what are called settlements which are essentially walled cities for Israelis built in the West Bank for Israelis, protected by the IDF (Israeli Defense Force). Often the Palestinians who were living there were force off their land and their homes bulldozed. These settlements violate international law, and have precipitated multiple UN resolutions against Israel. (Your reading for tonight is on Zionism and the map of Palestine and Israel).
Marty and Mark continue to enjoy our time here. We continue to enjoy all aspects of it. I apologize if I wax a little political. It is hard not to take up the Palestinian cause when seeing how again they are prisoners in their own country.
Check us out at pcrf.net/father-son-team-of-usa-vascular-surgeons-volunteer-in-Nablus/
PS we awoke to automatic weapon fire last night, but were told not to worry its was probably a wedding. And we just polka in Wisconsin.
Today we have two surgeries at Rafidi hospital in Nablus which is our last here. We will then go to Gaza City across a couple of checkpoints into the most unstable part of Palestine. We hope to stop in Jerusalem. We hope to have enough time to shop to bring back some fine olive oil, Arabic coffee, and famous Nablus sweets.
Please feel free to give us feedback as we are amateur writes of questions to be answered than interest you.
Boy did Spieth blow the masters.
Today we finished a femoral endarterectomy and femoral posterior tibial bypass, for chronic lower limb ischemia cased be plaques blocking the blood vessels. The operation from hell would be a fitting name. In vascular surgery when things go bad it can make life very difficult.
The first half of the operation went nicely but after we moved to the finishing anastomosis, the connection from the large upper arteries to the small lower arteries via a vein. There seemed to be a problem with the arteries of the lower leg and foot. After completion and bandaging the wounds there was no blood flow to the foot.
Here in lies the problem. In a country like this the facilities are sometimes sub-optimal. The Palestinians are very sophisticated and advanced. They have very nice operating theaters, however there is some equipment they have to make do without. The goal of this mission trip, that will do the most good, is for us to come see the facilities and see what is missing. On the next trip we will be able to bring the equiptment that the patients need to provide optimal care. So what we are going to do is make list of supplies and try to bring as much of it back for Dr. Ihab and the rest of the Palestinians.
After we determined there was no flow to the foot we reopened the incision. In the optimal circumstances we would do intrapretive angiography of the lower arteries to see where the occlusion was. This was not an option for us. They have a C-arm for the Xray however the tables are not radiolucent. We opened up the graft, we threaded a catheter down the distal arteries for the embolectomy and removed several small clots. We had reasonable outflow so we closed again.. no flow.
We opened again, went more distal with the graft passed an area of stenosis, plaque, and possible small dissection in the artery. We reattache the graft more distal. We closed… no flow. Our final option was to use more vein and take the graft further down the leg in hopes of getting circulation to the foot and save the patients limb. We anastamosed the graft to the posterior tibial arter deep in the calf, preformed another embolectomy and closed. After 9.5 hour operation we were had a good anatomist, and good runoff. We got a the pulse in the posterior tibial with a good biphasic doppler wave. Unfortunately the dorsales pedis was not as strong, but it was audible.
This patient has very treatable disease and the people here have the knowledge to treat. We are going to make a list of things that we will bring back and to Rafiti Hospital and the people of West Bank.
- Angiography equipment
- basic endovascular equipment
- Webster cannulae
- tunneler for fem pop bypass
- balloon occluders and catheters
- artificial graphs and patches
- Silk ties!!
- Sclerosant-polidocanol solution
- fogarty clamps
- ultrasound equipment
- papaverine vaso dialator
- a full team: Two nurses, and an Anesthisiologis
I know I’ve tantalized you with the mysterious blue suitcase and I’ll tell that episode. But first the barbecue.
Our host surgeon Dr. Ehab has taken us under his wing. He is a very gifted vascular surgeon working is sometimes less than ideal circumstances. He says we have everything we just cant use it. Which is and isn’t true. They have a lot of stuff we have to ration or rarely use and the just don’t have a lot of specialized equipment. And help are very nice people but don’t know how we work, nor highly attentive. Today was Marty and my day to create access for dialysis patients doing 5 fistulas in an outpatient. Things went well but for you medical people out there to get an idea of the conditions we operate under often less than ideal. We decided its part of the experience.
As mentioned Dr Ehab is a very good surgeon but an even better person. Last night we went to his house for a Palestinian barbecue with his four children (8months through 7 yrs), his wife who teaches medicine at the local medical school, his mother in law who cares for the kids and his father in law who does the garden but unfortunately recently suffered a severe stroke. The night was highlighted by Marty bonding with the kids. As I said the last blog people are the same everywhere. Here the father in law, Dr Ehab, and the 7 and 3 year old boy took turns playing with the fire and almost setting each other or themselves on fire. A remnant of men everywhere from our cavemen days. I know I have it. The menu was pure Mediterranean. Multiple Mediterranean vegetables as well as several types of olives, hummus, with a special type of Palestinian ground something meat combo, onion, tomato, and chicken kaboobs. The only thing difficult to eat was the sheep liver kaboobs. Marty and I did not have seconds on that. The first alcohol of the trip was what was called ARAQ, I have no idea what it was but tasted like fire. It was a memorable evening.
Dr Ehab grilling (center above), Marty bonding
Now the short version of the case of the missing (no longer) blue suitcase.
As you all know I lost my suitcase. No big deal except my magnifying loupes were in the case, which for an old surgeon doing fine work is a problem. The lost and found assured me no problem as the airlines Al El and Israeli airlines we were switched to (that’s another story) said but turns out it was a big problem. No Israeli (Jewish) delivery an deliver a large blue suitcase to Nablus West Bank Palestine (Muslim) and no West Bank(Muslim) currier can go to Israel(Jewish) and pick up a suitcase. I was told I had to go myself.
After our second 12 hour day we had supper and at 9 pm I started out with a driver for Ben Gurion airport in Tel Aviv which should be a 2 1/2 hour round trip. No problem. The first check point slowed us down a bit as well as getting behind a slow woman in full Muslim scarf texting and driving (see people are the same everywhere. But the roads are excellent, the speed limit isn’t enforced, and a taxi driver who likes to drive crazy fast or get home quick (not sure). No problem.
Until we told the security checkpoint which looked like a military camp that we were picking up a blue suitcase at the airport and taking in to Nablus, West Bank. We were force into a little detention parking space. I was an objective observer but my Palestinian driver who lives in Israel and holds an Israeli card, speaks perfect Hebrew, Arabic, and English was furious as were the Israeli military. One could feel the hatred. His face was red. We were separated and interrogated, searched, as was the car thoroughly gone over, and then just made to wait. My driver chain smoked the whole time. The Israelis were quite intimidating save one very nice one who talked to me. They wore full body amour and all carried automatic weapons and side arms. Were all body builder type. The Palestinian taxi driver at one point was surrounded by 4 and there were several more at the checkpoint. It was very intimidating. Finally at the airport they were pretty good to me but again the Palestinian was questioned. It took us over 4 hours round trip. I returned to our hotel exhausted.
I relate this obviously not to be humorous, but this is the way of life over here. This is very common. Israel rules with an iron fist. But the Palestinians consider this their country by right. They call Israel 1948land, meaning that’s when Israel won the first Arab Israeli war and that is the land that established Israel. Maybe more on this later but the mutual hate is palpable. We are living with the Palestinians and they feel like prisoners in their own country. As I watched this I noticed a wedding ring on one of the soldiers, and my driver had pictures in his cab af his two young kids. So they were basically the same age and spot in their lives. They were the same just on opposite sides of and ethnic and religious fence. The middle east is going to need the worlds help to figure this out is about all I’m sure of for now.
The people live their lives and are happy, its a pretty modern state here. But this is just below the surface always. A humorous example was during one of our very long cases we had a young muslim tech. Her name was Essrah. The women here cover up themselves except their eyes and they make their eyes up which are naturally beautiful with care. Marty and her were talking and for some reason he forgot her name and called her Israel. That would be worse than when I was a kid at my Lutheran church to mention the pope, sign the cross, or worse yet call the service a mass. You could have heard a pin drop.
Marty and I otherwise are doing well. We played a little cribbage tonight. I know why I don’t like cards as I always lose. I forced myself to exercise, we went for a walk, as its beautiful here, wanted to blog. The only bad part is I’m missing the Masters. And you guys all get on Marty for not writing enough. Otherwise all is well in Nablus West Bank.