What kind of treatment do patients on respirators get? The candid testimony of a technician who worked at Ichilov Hospital in Tel Aviv, and reports from workers at other hospitals, point to technical mistakes likely to cost lives
On any given day, there are several dozen patients at Ichilov Hospital in Tel Aviv on respirators. These patients are considered to be best treated in intensive care units (ICUs), but due to a shortage of hospital beds, 30-50 patients on respirators must be hospitalized instead in internal medicine departments, in what Ichilov's administration terms as "less than optimal" conditions.
In addition, every day several dozen patients need to receive oxygen with an oxygen mask or by other methods.
Respiratory technicians are responsible for the equipment and the respirators, working in shifts to provide service 24 hours a day. A team is supposed to be present when a patient is attached to a respirator, and to respond to calls from staff in case of a technical problem. In addition to respiratory technicians, the team also includes medical technologists, who have studied in academic institutions and specialized in respiration. Furthermore, medical and caregiving staff is supposed to monitor the patients at all times.
However, Mark Feuer, a respiratory technologist who worked in Ichilov for about three years (from January 1996 to 1999), reports that he repeatedly discovered serious mishaps and mistakes in the hospital in monitoring the respiratory equipment and in the care of patients receiving artificial respiration. The mishaps occurred both as a result of actions by nurses and doctors on the hospital wards - mainly in internal medicine units - and actions of respiratory technicians. Obviously, malfunctions or failures in the respiratory equipment are liable to cause severe harm, or even death, to the patient.
Feuer provided detailed and unprecedented testimony to Ha'aretz after he was dismissed from the hospital and left the country. Ichilov Hospital said he was dismissed due to repeated conflicts with the hospital staff, "mainly because of cultural differences that Feuer could not overcome." Feuer received his certification to administer respiratory treatment before he immigrated to Israel. A senior administrator at Ichilov admitted that even if there were serious complaints about Feuer's character or behavior, it is clear that his testimony is cause for concern, and requires a serious response on the part of the hospital.
Supervision of respiratory patients at Ichilov was tightened, beyond common practice in other Israeli hospitals, after the oxygen system of the hospital was accidentally cut off during renovations in 1994. At the time, many patients were harmed, and the functioning of senior members of the staff was brought into question.
Feuer's testimony goes well beyond exposing those failures, and illustrates a much more comprehensive problem. Testimony from medical technologists, nurses and doctors in other hospitals (including the Sheba Medical Center in Tel Hashomer, Beilinson Hospital and Hasharon Hospitals in Petah Tikva, and Soroka Medical Center in Be'er Sheva) indicates that all is not well at those institutions either. Operation of respiratory equipment is not always sufficiently supervised, some of the medical and caregiving staff are not sufficiently skilled in this field, and are sometimes even guilty of not taking the job seriously, hospital employees say.
In October 2000, there was a serious malfunction in the supply of oxygen during an operation in Hasharon Hospital. The investigation of the malfunction revealed failures in the supply of oxygen in the hospital. A hospital spokeswoman said that there was no connection between the malfunction and the maintenance of respiration machines.
Senior workers at a number of hospitals claim that despite repeated mistakes in the operation of essential medical equipment, such as respiratory equipment, the Health Ministry does not require sufficient formal training for medical technologists and technicians. Nor does it provide sufficient supervision of their training and their work. The medical technologists and technicians are responsible for operating crucial medical equipment in all the hospital departments, including equipment used in the operating room, and equipment for respiration, anesthesiology, dialysis, intensive care, pacemakers and cardiac catheterization.
Recently, Health Ministry Director General Boaz Lev has in fact issued new directives to medical technologists in the hospitals, but senior staff claim that the instructions are insufficient, and that the ministry must intensify supervision of those responsible for the equipment.
No formal training
Feuer immigrated to Israel at the beginning of the 1990s, after being formally certified in the United States as a respiratory therapist, and working in hospitals there. In Israel he was hired at Ichilov, where he discovered to his surprise that some of the workers responsible for respiratory equipment were not professionals who had undergone adequate medical training, but people who had received most of their training on the job.
Ichilov's administration largely concurs with Feuer on this point. The hospital said that in fact, "There is no definition of the formal training required for a respiratory technician. Feuer came from the United States, where respiratory technicians undergo training that grants them a certificate, but in Israel the field is still not organized, and training of respiratory technicians comes mainly from experience gained on the job."
The administration of Hasharon Hospital in Petah Tikva also blames the Health Ministry for inadequately organizing the work of respiratory technicians. Their comment came in response to complaints that the person responsible for the respiratory equipment in Hasharon Hospital has no formal training as a medical technician or technologist. According to the hospital, "There is no Health Ministry guideline demanding that respiratory machines must be handled by a medical technologist or a respiratory technologist, and to the best of our knowledge, the ministry does not intend to issue such instructions."
But the new guidelines issued by the Health Ministry on the work of medical technologists, including those who work with respiratory equipment, say that only a medical technologist with certification recognized by the ministry "is permitted to work in the profession, and may be employed in it."
Feuer says that while working in Ichilov, he was aware of a series of mistakes in the maintenance of respiratory equipment and the administration of oxygen to patients, as well as mistakes related to basic procedures of respiratory intensive care. But the nurses refused to listen to him, made fun of him and "insisted on focusing on my poor Hebrew." During his years at Ichilov, Feuer warned the deputy director, Dr. Avi Hessner, about some of the problems.
Feuer adds that he also came across a series of slipups and "critical mistakes" in the treatment of patients receiving artificial respiration. There were cases where the oxygen masks were placed on the patients without a sufficient flow of oxygen, or without any flow of oxygen. Every time he commented about this problem to nurses or doctors, they refused to listen to him or laughed at him, he claims. He also notes that there were cases when the caregiving or medical staff did not consult with the respiratory team when the respiratory equipment was found to be faulty. There were cases when the respiratory tube was attached to the patient incorrectly, and the tube moved out of place and had to be reattached, which causes great pain and suffering to the patient.
Feuer says he witnessed cases in which the caregiving or the medical staff did not wait for the respiratory intensive care staff to adjust the respirator and hook up the patient, which is proper procedure. In some cases the respirator was incorrectly adjusted. Feuer says that there were cases in which nurses suctioned mucus from patients - a procedure which is painful and traumatic for the patient - as an automatic response to the operation of the respirator alarm system, without checking whether the patient was actually in need of suction.
Feuer adds that there were cases when the respirator was not working properly, and the patient was not given manual respiration meanwhile, as required. There were also cases where even when a team of respiratory technicians was called, the patient remained hooked up to the broken machine, without supervision.
Ichilov's administration admits that they "occasionally" come across slipups such as those Feuer warned about, partly because of the need to hospitalize patients on respirators in wards for internal medicine, due to a lack of beds in the ICUs. Nevertheless, the hospital replied that, "No patient is put on a respirator without the supervision of a respiratory technician who makes sure the attachments are properly done," and that the skilled team of respiratory technicians includes a respiratory technician with professional training acquired abroad.
Ichilov also responded that the respiratory technicians are full partners in every resuscitation performed at the hospital, and that every day they monitor all the patients on respirators, and turn in a written report. There are also regular training sessions for the caregiving staff in order to improve their skills in caring for patients on respirators.
Feuer documented cases that reinforce his claims about what is happening in Ichilov. On April 2, 1998, in the afternoon, he found a bedridden 72-year-old patient suffering from Parkinson's Disease in Ward C, who was attached to a manual respirator, without supervision. He says that the patient turned blue and suffered from a racing pulse, since the flow of oxygen to his respirator was not sufficient for sustaining life. Feuer says he increased the flow of oxygen, started manual resuscitation, and informed the ward that the patient was full of secretions and needed suction as soon as possible. He attached the patient to a nearby respirator, where he had been previously hooked up. He informed the doctor on duty in the ward and the caregiving staff, and the next day reported to the person responsible for the respiratory technicians.
Ichilov responded that the patient's medical file contains no mention of the respiratory problem, and there is no documentation of Feuer's report of the problem.
In another case, in April 1998, in Ward B in internal medicine, Feuer discovered mistakes in the assembly of an oxygen mask in a patient who had been admitted to the hospital in a semi-conscious state. He says that the patient was given the wrong dosage of oxygen, and was attached to the oxygen mask due to neglect of a problem in the respirator. He says that he reported the incident to the person in charge of the respiratory technicians and to Hessner.
Ichilov responded that the patient's chart contains no mention of problems in administering oxygen, and that the patient was released after four days, with an improvement in her condition.
Feuer says that on Friday, May 5, 1999, he discovered critical mistakes in the attachment of the respiratory equipment to two patients in Ward C in internal medicine. In both cases, the mistakes endangered the lives of the patients. Feuer says that he approached the ward nurses, but they answered him mockingly and said, "The patient didn't die, did he?" He says that in this case, too, he reported by phone to the person in charge of the respiratory technicians and to Hessner.
Ichilov responded that the mistake, which was in fact reported to Hessner, "was repaired without any harm to the patient" and that at the same time, nurses in the ward complained about Feuer's attitude toward them.
In another case, on the night of December 12, 1999, Feuer was called to check a problem in the respiration of a 100-year-old patient who had been hospitalized in Ward B because of high fever, edema and cardiac arrest. The patient was given a bed in the ward corridor. Feuer says he discovered mistakes in the operation of the patient's respiratory equipment and reported it to the ward doctor, to the nurses, and to the head nurse. The next day, the patient died.
Ichilov responded that in the patient's file there is no mention of the problem.
In July 1998, after a series of mistakes in the operation of respiratory equipment, Feuer wrote to Hessner: "Despite my attempts to teach and warn those people mentioned in connection to unsafe and dangerous procedures being carried out on patients on respirators, I have discovered that these mistakes are constantly being repeated, and are endangering lives. I have tried to operate within the hierarchy of the nursing staff, but have often been ignored by the others, who say, `I'll take care of it,' but actually do not do so, or I have been ridiculed. Unfortunately, because of this attitude on the part of the nursing staff, the patients are the ones who suffer greatly.
"As a respiratory therapist/technician with certification from a U.S. university, I feel it my duty to put the safety of the patient first. I am also obliged to teach others, and to point out problems before tragedies occur. The opposition I have faced stems from fear of new ideas and new approaches that will improve the quality of care received by patients in Ichilov.
"Undoubtedly, there are many patients who would not be in need of cardiac catheterization and resuscitation had they received proper care in the first place. It may have been possible to save many people who were attached to respirators and died eventually, had the staff members who treated them received proper training. Unfortunately, this is not the situation. There are a great many cases of severe neglect, which you should be aware of. I think that these cases are hidden from you, and whitewashed."
Ichilov responded that in December 1999 Feuer was dismissed "due to repeated complaints on the part of the hospital staff regarding his behavior," and that even earlier, in January 1999, he was reprimanded and a comment was entered in his personal file "for unprofessional attachment [of a respirator] in the children's ICU." Despite this, after the mistake, the Ichilov administration allowed Feuer to work for another year monitoring and operating the respiratory equipment in the hospital.
Who takes care of you?
About 1,500 medical technologists and technicians are part of hospital staffs. But they are less familiar to the public than doctors and nurses, although they are responsible for operating medical equipment, performing tests and administering treatments that are directly connected to the life and welfare of patients.
According to new guidelines published by the Health Ministry in recent weeks, the ministry recognizes 23 medical technology professions, including those dealing with anesthesiology, respiration, the operating room, intensive care, dialysis, isotope mapping, pacemakers, cardiac catheterization, echocardiography (heart ultrasounds), heart-lung machines, et al.
The new circular was published in the wake of complaints by the association for the advancement of medical technologists in Israel. The association claims that there are not enough official definitions for requirements of the profession, and the activity of medical technicians/ technologists is carried out without sufficient supervision and monitoring. Certification as a medical technologist requires three years of study in institutions recognized by the Health Ministry.
A veteran and senior medical technologist says that in many hospitals, medical technicians carry out medical activities, although they have not been certified and trained to do so. He termed this a scandal. The activities include injecting materials into the oxygenator of a heart-lung machine, or injecting the patient with isotopic materials intravenously. The Health Minister responded that complaints on the matter, if received, will be handled as required by law.
Senior medical technologists also claim that the Health Ministry and the health maintenance organizations do not treat the profession seriously enough, and that the salary is insufficient. They also claim that in most of the operating rooms in the hospitals, there are not always certified medical technologists, and that there is not a system of continuous rotation and a duty roster, although sometimes there is an urgent need to examine or to operate essential medical equipment even during the night, and on Shabbat and holidays.