A Touch of Delirium and a Silver Badge: Challenges of Integrating Security and Healing in Hospitals

Originally published on the in-House blog http://in-housestaff.org/touch-delirium-silver-badge-challenges-integrating-security-healing-hospitals-807

Art by Sheyda Aboii

“They’re killing me,” Mr. S. whispered to me in Spanish, fear flashing across his eyes. “I have to get out of here.” He yanked his legs upward, but the soft restraints tied around his ankles tugged him back, tethering him to his hospital bed.

I first met Mr. S. two nights ago, when I admitted him for a urinary tract infection. We had a pleasant chat about his loving son and his work as a carpenter before he retired. In the last 24 hours, however, he had become confused and delirious. At midnight, I received an urgent page: “Patient S agitated, pulling at lines, threatening staff. We’re calling security now.” I made a beeline to his bedside, crossing my fingers that I’d get there before the armed officers.

Enforcement and Health Care

I work at one of several hospitals in the country whose security force is staffed by law enforcement personnel. It’s also one of the 52 percent of hospitals nationwidewhose security guards are armed with handguns. On a regular basis, I am faced with a peculiar tension that arises when health care priorities misalign with apparent security goals. On the one hand, there are the unpredictable needs of sick, vulnerable, and, at times, unstable patients. On the other hand, there are the day-to-day stressors experienced by staff and the occasional real threats to their safety.

Unfortunately, in trying to negotiate this tension and promote safety via security officers, all too often the patient ends up feeling more vulnerable, attacked or even unsafe. In some extreme instances, there have been cases of assaults, shootings, and Taser attacks on patients by hospital-based security personnel.

Control versus Cure

I was nervous that evening as I scurried up the stairwell to Mr. S’s room, wondering what would happen when he was confronted with the security guard. When I arrived, I saw four nurses crowded around his hospital bed, making the final adjustments to the restraints by fastening the soft cotton rings around his ankles and wrists and pulling the straps tightly to the metal frame of the bed. There was no sheriff in sight. I exhaled — relieved — and moved quickly to the head of the bed. Mr. S was mumbling, his eyes darting from me, to the vitals monitor, to the aide, to each of the nurses in the room, clearly delirious and tugging at the restraints. I crouched next to him, listening to his concerns and speaking to him in soft, calm Spanish, “We’re here to take care of you, Mr. S. You’re here in the hospital. Your son is coming to see you tomorrow. Everything is going to be okay.”

And just as it seemed like Mr. S was starting to relax his pull on the restraints, a new voice bellowed from behind the privacy curtain in his room. “Sir, you will have to calm down.” We turned to see a uniformed sheriff’s officer emerging at the foot of the patient’s bed, barking orders in English. The patient looked startled for a minute, his eyes clouded, then he quickly resumed his tugging and yelling. “The race is coming, I have to go in my car right now!” he shrieked. The officer didn’t blink, clearly not understanding the patient’s Spanish. “Calm down,” he shouted back English, his gun bouncing off his hip.

But Mr. S’s agitation was mounting. Suddenly, he had an arm free and the sheriff jumped on him along with the other nurses. Mr. S. fought back harder now, spitting and swearing and flailing his arms. The sheriff grabbed the patient’s left arm, held it down, and leaned his weight into it as his holster banged against the hospital bed.

Security for Whom?

As I think back to this moment with Mr. S, I am struck by how helpless I felt. While I had a clear idea of what the patient needed medically — reorientation, soothing, establishing familiarity — the sheriff seemed to have a completely different agenda. Indeed, our strategies as health care providers often come into conflict with those of security personnel due to a fundamental difference in training and perspective. Health professionals are trained to see the patient as a whole, to think about the root of a patient’s illness or behaviors, and to provide compassionate treatment. In contrast, law enforcement culture traditionally focuses on detecting threats and responding quickly and accurately to eliminate those threats. It can therefore be incredibly challenging to come up with a shared vision between care providers and security personnel to address safety concerns involving patients, especially during one-off or emergent encounters.

In addition, the story of Mr. S illustrates how power dynamics impact a patient’s experience of a security force. Traditionally, patients in the hospital are in a relatively disempowered role — feeling ill, awaiting diagnoses, getting poked and prodded, being asked to share deeply personal aspects of themselves with people they just met. Not to mention the possibility that patients may be in psychiatric distress, unable to control their bodily functions, or unable to communicate. The presence of new authority figures such as security guards who generally respond only in crisis moments can thus be particularly intimidating for a patient who may already feeling vulnerable.

This feeling of vulnerability can be further compounded by cultural and language differences. Despite regulations establishing language access services in hospitals across the United States, there are still instances in which patients are not provided with the culturally sensitive care and interpretation or translation services they require. When these oversights are carried out by security personnel, as in the case of Mr. S., situations can quickly escalate when they may have been more easily resolved with adequate communication.

The unequal power dynamics related to security personnel are particularly salient when the officers are armed or part of a law enforcement body. While potentially a reassuring presence to some, patients who have previously felt targeted or discriminated against by law enforcement officers may find the very presence of these uniformed guards intimidating or disconcerting. This is certainly relevant at our hospital, which serves large numbers of undocumented immigrants, formerly incarcerated people, and people of color from neighborhoods in the city that have been disproportionately over-policed. To these patients, the presence of uniformed officers may re-traumatize them, even within the walls of an institution that aims to heal.

To be sure, there are instances in which the specialized approach of law enforcement can be appropriate. From 2012 to 2014, violent crime within hospitals and other health care institutions increased by 40 percent. In my own workplace this past year, an active shooter incident required a fast, specialized response by our security force to ensure the safety of all patients and staff.

Nevertheless, it is not necessary to apply this degree of force to the vast majority of everyday incidents our security personnel encounter. To the contrary, it is likely that applying excessive force to these everyday security challenges may actually escalate conflicts unnecessarily.

A Path Forward

What are the alternatives? Some hospitals have hired private security guards that are armed with nothing more than pepper spray and trained extensively in de-escalation. Other hospitals have developed crisis-response teams that include an interdisciplinary team of mental health professionals, social workers, and, when indicated, security guards. Some other hospitals have deemed their security force “peace officers” and made sure they dress in clothing that is not intimidating to patients who have a history of negative experiences with law enforcement. Whatever form the solution takes, it is clear that hospitals will benefit from honestly addressing the inherent conflict between health care and law enforcement, and have clear strategies in place to mitigate the tensions that arise.

Thankfully, in the case of Mr. S, things ultimately did deescalate. The sheriff left, I kept up my calming advice, and his agitation improved. Nevertheless, I’m convinced that a more thoughtful response and more coordination between all of us involved would have likely led to a more rapid de-escalation, and may have ultimately resulted in Mr. S feeling more cared for and safer, even in the face of his medical challenges. For Mr. S. and so many other patients, a shift in how we think about security and safety within our health care institutions is needed in order to truly foster a culture of caring and healing for all.

Standing Rock: Reflections on Health and Resistance

Boom! The crash of the firework rumbled through the medic tent at Standing Rock, North Dakota. Martin jumped and his hands grasped the legs of his aluminum folding chair, searching for stability. It was the evening of December 4^th, the day that President Obama had announced that the U.S. Army Corps of Engineers would not grant the permits needed to allow Energy Transfer Partners (ETP) to continue drilling of the Dakota Access Pipeline (DAPL) through sacred Lakota lands and water sources. Throughout the camps, there was exultation and celebration. Music, chants, and fireworks rang through the skies. However, inside the medic tent, the tone was more somber.

“I just can’t get the memory out of my head,” Martin explained a few minutes after the last bang, inching his chair closer to the propane stove, the orange glow reflecting off his eyes, “every time I hear that sound, it’s like I’m right back on the protest lines.” Martin, a Native American from the Shoshone tribe, was one of the thousands of water protectors who participated in the November 20^th peaceful protest that ended in hundreds of casualties, after police deployed water cannons, concussion grenades, rubber bullets, teargas, and pepper spray. Unlike many of the other water protectors from that day, Martin escaped any lasting physical injuries. However, the psychological impact of the events stuck with him, and have left him worried about facing a lifetime of PTSD.

Rosebud camp medic tent (Photo credit: Melody Glenn)

Martin’s story is just one of many stories that highlight the urgent public health implications of the injustice being carried out in North Dakota through the construction of DAPL. In addition to the mental and physical health impacts of police brutality, the pipeline project poses high risks to drinking water contamination in the region, which has been linked to increased rates of birth defects, seizures, and cancer. Furthermore, the way DAPL has proceeded in direct opposition to tribal demands and sovereignty perpetuates centuries of discriminatory practices and historical trauma that are at the root of multiple health inequities (including high rates of mental illness and chronic disease) that disproportionately affect Native American communities.

Oceti Sakowin camp (photo credit: Melody Glenn)

As a physician, I feel moved to fight DAPL out of a keen awareness of its negative health consequences and out of a love for my Native brothers and sisters. I also recognize that, as a white person born in the U.S., I have a responsibility to combat the centuries of colonialism, genocide, and oppression of Native peoples that have served to privilege certain groups and disadvantage others, and is thus deeply linked to my own history and lived experience in this country.

Now, with Trump in office and the Army Corps of Engineers announcing its intention to give the green light for DAPL to proceed, I am deeply troubled by what this will mean for people like Martin and the dozens of other resilient, passionate people I met during my time at Standing Rock. How many more people will experience the sting of pepper spray, the blow of the police club, the immobility of PTSD, before this fight is over? How many oil spills, poisoned water sources, and environmental tragedies will it take before lawmakers and business leaders take a stand for health and human dignity? I hope beyond hope that justice will come sooner rather than later; but I also know this will only happen if we all rise up, mobilize our resources and skills, and take action to fight the pipeline.

Resources for divesting from DAPL:

http://www.showingupforracialjustice.org/dapl_divest

http://lakotalaw.org/divest-dapl

http://www.yesmagazine.org/people-power/7-ways-to-make-an-even-bigger-impact-when-you-divest-from-dapl-20161201

Resources for clinical volunteering and donations:
http://medichealercouncil.com

Sunset leaving Standing Rock

Restricted Movement and Health in Palestine

I knew what was coming before it happened. She was looking up at the ring of white coats encircling her hospital bed, eyes darting from side to side to follow the sequence of their voices when suddenly, her lower lip began to quiver. And with her quivering lip, her breaths came faster and she sucked in deep gulps of air between her pleading questions. But soon the pack was headed on to the next patient on rounds. She was left alone, and the tears rolled freely.

Wael, one of the interns, and I hung back, offering the patient a few words of encouragement and a fistful of tissues. Wael explained to me (since I had missed much of the exchange due to my poor understanding of Arabic) that the woman had just delivered twins, prematurely, and that both babies were in the neonatal ICU requiring prolonged hospital stays. However, the woman herself was well and ready for discharge. The hospital needed her bed, but she was pleading to be able to stay, so she could be near her babies while they recuperated.

Prior to coming to Palestine, it might have been hard for me to imagine why a healthy new mother wouldn’t want to be able to get home as quickly as possible, even if it meant daily trips to the hospital to visit her children. However, after being here for nearly a month, her concerns seemed obvious.

Permission for entry

Al-Makassed Islamic Charitable Hospital, where I was doing my OBGYN clinical rotation, is located in East Jerusalem, a primarily Arab section of the city that since 1967 has lain within the demarcation lines of the Israeli state. However, as a referral hospital for Palestinians in the region, the majority of patients come from elsewhere; most are referred from the West Bank and some from Gaza. A smaller number of the patients live in Jerusalem itself, either as permanent residents of East Jerusalem or as Arab Israeli citizens.

Aside from the permanent residents and citizens of Israel, who are eligible for the Israeli blue ID, the rest of Makassed’s patients are green and orange ID holders, from the West Bank and Gaza respectively, and can only enter Jerusalem from the occupied territories if they have received a special permission from the Israeli government (Tawil-Souri, 2002). These permissions can be granted for certain specific reasons, such as medical referrals, and obtaining one can be a cumbersome process. Even if the hospital is aware of a clinical emergency and expedites the application, it can still take up to three hours to receive the needed permission. For non-emergent cases, it can take days. The situation is even worse for referrals from Gaza, where travel is most tightly controlled (World Health Organization, 2014).

Example of a Green ID. Source: holylandshots.wordpress.com

The travel restrictions make it virtually impossible to achieve standard for care for Palestinians, especially for emergent conditions. For example, if someone presents to a West Bank hospital with a heart attack, under specific clinical scenarios this would require cardiac catheterization within 90 minutes. Makassed has the facilities to perform this procedure, however if a patient does not have a prior permission to enter Jerusalem, it can be very difficult to get that patient transferred in time.

For both emergent and non-emergent cases, additional political hurdles can get in the way of patients getting the care they need. For example, some patients requiring specialty care may be completely barred from entering East Jerusalem due to presumed ties with political groups or past accusations (either accurate or inaccurate) of subversive activity.

It’s not only the patients in the hospital that have to contend with this process. Most of the hospital physicians, residents, and medical students at Makassed also reside in the West Bank. These colleagues all have to apply for and receive special permission to be able to commute into Jerusalem. And they are subject to the same political barriers. Mohammad, one of the medical students, tells me that some of his classmates at Al-Quds university are unable to do any of their rotations at Makassed, because they have brothers who were held as political prisoners many years ago. These young medical students are “guilty by association,” and are not allowed entry into East Jerusalem to complete their rotations.

Fear and loathing at the checkpoint

Once a West Bank dweller manages to receive permission to enter East Jerusalem for work or medical care, they still have to contend with the militarized checkpoints to get to the hospital and to their appointments. To get through the checkpoint, Palestinians and foreigners wait in a series of unpredictably-long lines in front of full-height turnstiles that periodically turn on and off, letting a set number of people through at a time. Once through, all objects and bags are passed through a conveyor belt, and the individual passes through a metal detector. Then each person shows their ID to the Israeli solider behind a glass separation wall, and their admittance is either approved or denied. Although recently it was announced that there will be some loosening of the check point procedures for the doctors working in Jerusalem, for the vast majority of Palestinians passing through the checkpoints, they will still have to go through the same process (Friedson, 2015).

A woman pushes through a turnstile at a checkpoint

Photo credit MAANnews/Mushir Abdelrahman

The daily grind of passing through the checkpoints is not only inconvenient (for example, it often takes someone from Ramallah more than three times as long to get to Jerusalem as it would if they rode there directly), it can sometime lead to outright harassment. My friend and co-medical student Marwa arrived at the hospital one day, frustrated and telling me that at the check point that morning, a button on her dress kept going off in the metal detector. The Israeli soldier asked her to take off her dress in front of all of the people, including men, who were also waiting at the checkpoint. For a Muslim woman, who is only expected to show her hands and face, this seemed outrageous, and Marwa was brave enough to resist and explain her religious preferences to them in English. Eventually, the soldier, who was female, relented and took Marwa into a private room to search her.

I was left wondering how that same encounter would have gone for a patient at Makassed who just received the permission to enter Jerusalem and may either be too nervous to speak up to the soldiers, or have too little English vocabulary to feel comfortable speaking to them (the Israeli soldiers usually speak a bit of English and little to no Arabic, so the Palestinians I met, the majority of whom don’t speak Hebrew, generally speak to them in English). Perhaps she would have been made to take off her dress in public and been thoroughly humiliated in the process.

Political art by Banksy on the Separation Wall

Here, a young girl is "patting down" an Israeli soldier

Political lines

Perhaps most striking about the experience at the checkpoint is how dispiriting and demoralizing the entire mechanized ritual feels. In many ways, it is an on-going reminder to Palestinians that they are under occupation and subject to constant scrutiny.

Prior to 1948, the year of al-Nakba (“The Catastrophe” in Arabic), when 700,000 Palestinians were forced out of their lands and the state of Israel was declared, Palestinians moved freely in and out of all of Jerusalem and the current Israeli territories. They visited friends and family in towns throughout the region, enjoyed the natural wonders of the land, and worshiped in their various holy sites. Between 1948 and 1967, the West Bank and East Jerusalem fell under the control of Jordan. During this time, in 1964, construction began on Makassed Hospital. By the time the hospital was inaugurated in 1968, it was just one year after the hospital had fallen within Israeli territory and the challenges of Palestinian access to the hospital heightened.

Al-Makassed Hospital. Photo credit: www.uaeinteract.com

Throughout this time, the enforcement regime of ID cards as a means of controlling and restricting movement was becoming more and more entrenched, although many Palestinians were able to travel in and out of East Jerusalem without special permissions (Tawil-Souri, 2002). In 1993, policies were put in place to prohibit entry without the special permission, however these were loosely enforced (OCHA Closure Update, 2008). Then in 2002, following the second Intifada, travel restrictions in the region were tightened significantly and additional mechanisms of control, such as curfews, were instituted.

These travel restrictions extend to travel outside of Palestine as well. Since 1995, West Bank and Gaza dwellers are eligible for the Palestinian Authority (PA) passport. However, obtaining visas for international travel can still be an expensive, time-consuming, and unpredictable process (Atallah, 2013). East Jerusalem residents are not eligible for the PA passport or an Israeli passport and must obtain a travel document from Israel every time they travel internationally (Atallah, 2013). And again, anyone who has gotten onto the “bad list” with Israel can be restricted from all movement, and end up stuck in either the West Bank or East Jerusalem. People living in Gaza are the most restricted due to periodic travel bans.

According to the Israeli government, these travel restrictions are necessary in order to ensure the security of Israel and its settlements (OCHA Closure Update, 2008). However, human rights organizations point out that Palestinians have disproportionately suffered the impacts of the conflict; between 2000 and 2007, more than 4 Palestinians have been killed for every 1 Israeli (OCHA Special Focus, 2007). Furthermore, the travel restrictions themselves, along with other aspects of economic and resource control, are contributing to overwhelming health disparities and other human rights violations against the Palestinian people (B’tselem, 2014). For example, the average life expectancy for Palestinians residing in Occupied Territories is 10 years lower than the average life expectancy in Israel (Efrat, 2015).

The pain of separation

Now, with the new mother of twins sitting in front of me, I think about all the variables that will impact her ability to see her twins on a daily basis. Firstly, she will need to have permission to come in to visit the twins. Secondly, she lives in Jericho, which is only 17 miles away from Jerusalem by map coordinates, however in practice, with the checkpoints and public transportation, it will likely take her between 4-5 hours round trip to travel each day from Jericho city, even more if she is coming from a village around Jericho. As a green ID holder, she might be prohibited from staying overnight in Jerusalem, since it is forbidden for West Bank dwellers to relocate to East Jerusalem. Even if she did try to stay overnight, without a family member or friend to offer her a room, this would be a very costly, likely unrealistic proposition, especially given the huge differentials in cost and wealth between Israel and the occupied territories. Finally, no matter her situation, she would be at risk of getting her permission taken away at any moment, and losing complete contact with her twins as they recuperate.

As the tears stream down her cheeks and she lets out a low sob, I feel frozen in the vastness of her struggle, in the beauty of her strength as a woman and mother. I notice own throat tighten and my tongue twist on itself, trying to remember the shape of the new sounds I am learning to form Arabic words.

But I know I can offer no support, no words of encouragement. What I really want to say is simply, “I’m sorry.” I’m sorry for all the times I’ve turned away, too distracted or uncomfortable to stare the reality of Palestine in its face. I’m sorry for whenever I’ve paused, hesitated to speak up against the U.S.’s self-interested meddling in the Middle East. I’m sorry I went so many years without questioning, without pushing back against the lies the media tells… I’m sorry that I haven't done more.

I hand her a tissue and she mutters thanks, turning her eyes up to meet mine. I squeeze her hand and will my eyes to communicate my message to her… But she looks away quickly, gives a weak smile, and turns her whimpering towards her hands.

Wael stands at the foot of the bed. “Yalla, Juliana,” he says softly, “let’s go”. And we move on to re-join rounds and listen to the story of the next patient.

Observing the scene from a balcony in Abu Dis, West Bank. 

From this same balcony, in the other direction, the separation wall can be seen.

References:

Atallah, Diana. Palestinian passports rejected by citizens. The Jerusalem Post. July 4, 2013.

B’tselem. 47 Years of Temporary Occupation. Jerusalem: 2014.

Efrat, Mor. Divide and Conquer: Inequality in Health. Physicians for Human Rights Israel: 2015.

Friedson, Felice. Physicians are first to be given permits to drive to work inside Israel. The Jerusalem Post. April 25, 2015.

OCHA Closure Update, Occupied Palestinian Territory. United Nations Office for the Coordination of Humanitarian Affairs, East Jerusalem: 2008.

OCHA Special Focus, Occupied Palestinian Territory. Israeli-Palestinian Fatalities Since 2000 – Key Trends. United Nations Office for the Coordination of Humanitarian Affairs, East Jerusalem: 2007.

Tawil-Souri, Helga. Colored Identity: The Politics and Materiality of ID Cards in Palestine/Israel. Social Text 107 29, 2: 2011.

World Health Organization. Occupied Palestinian Territory, Conflict escalation in Gaza – complex emergency. WHO Regional Office for the Eastern Mediterranean. Situation Report #6: 2014.