Celebrating health care in t&t issue

Caribbean Medical Journal

Official Journal of the Trinidad & Tobago Medical Association

EDITORIAL COMMITTEE Editor

- Dr. Solaiman Juman

Deputy- Editor

- Dr. Ian Ramnarine Dr. Rasheed Adam Dr. Rohan Maharaj Dr. Kameel Mungrue Professor Terence Seemungal Dr. Darren Dookeram Mrs Leela Phekoo

ASSOCIATE EDITORS

Dr. Dilip Dan Dr. Eric Richards Dr. Sonia Roache Dr. Donald Simeon Dr. David Bratt Dr. Lester Goetz

ADVISORY BOARD

Professor Zulaika Ali Dr. Avery Hinds Professor Gerard Hutchinson Professor Collin Karmody (USA) Dr. Michele Monteil Professor Vijay Naraynsingh Dr. Alan Patrick Professor Lexley Pinto-Perreira Professor Samuel Ramsewak Peofessor Grannum Sant (USA) Dr. Ian Sammy Professor Surujpal Teelucksingh

PUBLISHED BY

Eureka Communications Limited

No part of this Journal may be reproduced without the written permission from the publishers

Caribbean Medical Journal

Editorial As our Nation celebrates our 50th year in which we are responsible for our own destiny, questions about the Health of Our Nation come to mind: What is the current status of our Healthcare and what is our plan for the future?

On the face of it, these are difficult questions to answer; but they must be answered!

The Public has access to free medical care and this is our right. This encompasses a wide array of services. The Primary Care Facilities offer from Chronic Disease Assistance Programme (CDAP), Point of Care Testing and many other services. These are geared towards the management of chronic diseases and early detection of complications. In addition to the services that are expected at the secondary and tertiary care facilities, our hospitals now also provide access to complex, expensive services such as Renal Transplantation, Cardiac Stenting and Surgery. These services are now performed as routine. The development of these services has also allowed for emergency Cardiac Procedures, such as Stenting, emergency Cardiac Bypass and Repair of Aortic Dissections to be performed. Cancer services have also expanded and Palliative care has been evolving.

Our healthcare service is the envy of the rest of the English-speaking Caribbean.

Like most countries, there exists a dual health service with Public and Private options. Advantages of Private care include the shorter waiting time and Specialist-provided (as opposed to Specialist-lead) Healthcare. But there is a cost to this privilege! Yet still it is encouraging that a wider variety of services are available within the Public facilities. Both the Government and individuals alike explore this duality and utilise a blend of both services. We are provided with so much, yet still, access and availability are limited. Why is the Public Health Service failing so many of us citizens? Improvements within the Health service are largely under-reported and not publicised well. “The evil that men do lives after them; But the Good is oft interred with their bones!”

Good news about health does not sell as many newspapers as does the reporting of any adverse event!

What are the failings of the Public Health Service? They appear to be too numerous to cover in this editorial. Or are they? What is the Plan? Do we have a plan?

For a Nation this size, it should be easy to enumerate the healthcare services required and the staffing, equipment and organizational requirements; even the number of hospitals required. The number, size and location of hospitals should not be left up to political fancy or to be used for political gain. Too many promised facilities have been delayed or dropped altogether at considerable expense, and often because of political motives. Too often the problems at the delivery end of healthcare lie with the management and the bureaucrats. For example, how can a managing authority be expected to function if there is no plan of services to be offered, the number of procedures, the cost of the procedures, or even knowledge of the personnel required to carry them out.

There is often the impression that there is no budgeting or planning going on. If these plans exist they are clearly ineffective, how else can one region run up estimated debts of $100 million.

Experts trained to do so should commission the Blueprint for a Healthy Nation. Politics and Politicians should not affect this Blueprint.

But what can we as Health Care Providers (Yes! That’s what we are called in the Blueprint) do to improve patient care? First, we must realise that Health costs and we must learn to practise cost effective medicine. Next, Clinical Governance must be adopted as our own. The only way to force the administration (and even the Politicians) to make changes that will improve patient care is to report the facts and figures. One local Audit demonstrated the difference in outcomes by two groups of surgeons. This resulted in a change in the direction of a major project that had political implications. Before the change was effected it was necessary to do the hard work of data collection, analysis and preparation. Then (most importantly) it was essential to have someone to champion the information through to the policymakers and the politicians.

The US and UK have both been going through major health reforms that have resulted in no end of problems for Health Care Providers and patients alike. So our problems are far from unique. We as Medical Professionals have an opportunity to impact on the direction we take. But, we cannot influence the policymakers without doing the hard work of Clinical Governance, despite the handicaps of staff and equipment shortages. Everyone wants progress - but are we prepared to make the changes required to get there?

Ian Ramnarine FRCS Guest Editor

Caribbean Medical Journal

Contents Original Scientific Article The prevalence of depression and its associated factors among elderly patients attending Health Centres in Trinidad Original Scientific Article Is it time to replace 24-hour urinary albumin excretion (UAE) assessment in Trinidad and Tobago?

Original Scientific Article Challenges of providing comprehensive clinical service within the public health sector: a case study of the Paediatric Oncology service Original Scientific Article Introduction of a Simulation Laboratory to Preclinical Students at St. George’s University in Grenada Case Report Exposed Fracture of the Medial Malleolus: the Role of the Reconstructive Ladder Case Report Urethrocutaneous fistula post circumcision Cardiology The Cardiac Catheterization Lab: Implementing Best Practice in Trinidad and Tobago Psychiatry Substance Abuse as A Public Health Problem Audit A six year review of the head and neck cancers at the San Fernando General Hospital 2004 – 2009 Commentary Family Medicine, CCFP, Wonca and Trinidad & Tobago Palliative Care Report on the First Palliative Care Conference in Trinidad and Tobago Medical Philosophy The Good Samaritan Medicolegal Ethics in the everyday History A brief history of Chest Medicine & Surgery in Trinidad & Tobago Icons of Medicine AJF ‘Fred’ Penco-Pioneer of Thoracic Surgery in Trinidad & Tobago From the Archives Dr. Premchand Ratan Postgraduate Training DM Otorhinolaryngology (ORL) Elective Report Internal Medicine Elective at Eric Williams Medical Sciences Complex, Trinidad T&TMA Inauguration Dinner 2012 Medical Research Conference University News The Honourable Kamaluddin Mohammed Meeting Report Trinidad and Tobago welcomes….. the Commonwealth!

Obituary Professor Hari Maharajh Taking it Easy The art of medicine

ISSN 0374-7042 CODEN CMJUA

1-4 5-7

8-10 11-15 16-19 20-21 22-26 27-30 31-34 35-37 38-41 42-44 45-46 47-49 50-51 52-53 54 55 56-61 62-63 64 65-66 67 68

Caribbean Medical Journal

Original Scientific Article The prevalence of depression and its associated factors among elderly patients attending Health Centres in Trinidad K. Khan MBBS, V. Abiraj MBBS, R. Baboolal MBBS, A. Beharry MBBS, R. Beharry MBBS, R.Boithamako MBBS, S. Chiyapo MBBS, R. Harrinarine MBBS(Hons), A.Jagoo MBBS, C. Mattis MBBS, C. Nagalingam MBBS, T Sankar MBBS, R. Sharma MBBS, A. Sookhai MBBS, F.Tam MBBS, Diploma in Family Medicine, M. Dissayanake MBBS, A. Ferdinand MPH & R.G. Maharaj DM, FCCFP. Faculty of Medical Sciences, University of the West Indies,St. Augustine, Trinidad.

ABSTRACT Background Depression is the most common mood disorder in the elderly.

Internationally, most studies have found the prevalence of depression in the elderly population to range from approximately 13% to 18%. In 2010 it is estimated that persons over 60 years of age made up ten percent of the population of Trinidad and Tobago The ageing population faces many complex issues such as chronic illness, disability, loneliness, isolation and adverse socio-economic circumstances that may contribute to depression.

Locally, no studies have been done that investigate depression specifically in the elderly. This study aims to establish preliminary data on this topic for the elderly population of Trinidad.

Methods This was a cross sectional descriptive study of patients over age 60, attending four health centres in Trinidad (Arima, St. Joseph, Freeport and Couva). Convenience sampling was used and participants completed a demographic questionnaire and the Zung self rating depression scale. Data was analyzed using SPSS for Windows version 10.0 and the Chi-square test was used to determine statistically significant associations.

Results There were 348 participants consisting of 200 females (57.4%) and 148 males(42.6%). Those 60 -79 years made up 90.8%, while the remaining 9.1% were 80 years or older. IndoTrinidadians made up 60.1%, Afro-Trinidadians 31.2% and mixed or others made up 8.7%. The prevalence of depression in this elderly population was found to be 17.2%. Depression was found to be associated with level of education (p=0.016).

No association was found between gender (p=0.470), marital status (p=0.066), ethnicity (p=0.742), living arrangement(p=0.059) or the presence of a chronic medical illness.

Conclusion The prevalence of depression found in this population (17.2%), its association with level of education is comparable to that found in other elderly populations internationally. Depression is intertwined with social and economic well being and selfperceived health and is an important consideration when caring for the elderly in Trinidad.

Background There has been significant growth of the elderly population in the Caribbean, according to the Central Statistical Office

approximately 10% of the population of Trinidad and Tobago in 2010 was over 60 years of age [1]. The United Nations Population Division has projected that this age-group, which constituted 4.5 per cent of the Caribbean’s population in 1950, will increase to 18 per cent in 2050 [2].

This increasing longevity brings with it new challenges both medical and social. Elderly persons face complex issues unique to their population which can contribute to chronic depression and feelings of sadness. These include having one or more chronic diseases or disability that causes functional or cognitive impairment or requires complex medication schedules. It is well established that an association exists between chronic disease and depression [3,4]. A study by Rawlins which explored health, social and economic status and issues of loneliness in Trinidadian elderly showed that the prevalence of at least one chronic disease in the elderly population is as high as 80%[5].

This statistic suggests that this could indeed play a significant role in the depressed elderly. In the same study, Rawlins et al revealed that of 864 elderly persons surveyed, 33% reported feelings of loneliness citing main reasons as ‘family and friends too busy’ and ‘living alone’[5].

A reduced sense of purpose may accompany retirement or limitations placed on activities such as driving. Many are faced with bereavement of friends, family and spouses. Fear of illness, dying or anxieties over economic hardships can also contribute significantly to depressed mood.

Given the economic and social burden of depression worldwide, [6,7] it would be useful in planning and executing health policies for our elderly population to have an idea of its prevalence; as well as to be able to identify any socio-demographic factors that may be associated with its presence.

U.S community studies have shown that 25% of elderly persons report having depressive symptoms, 1% to 9% meet criteria for major depression; while higher prevalence rates are reported in the hospitalized elderly (36% to 46%) and those in long term care facilities (10% to 22%)[8].

Locally, no studies have been done that specifically focus on depression in the elderly population. The majority of studies have focused on depression and suicide [9-15] and depression in adolescents, [14-17]and a few on depression in primary care[18-20].

A study among patients attending chronic disease clinics in 1

Caribbean Medical Journal THE PREVALENCE OF DEPRESSION AND ITS ASSOCIATED FACTORS AMONG ELDERLY PATIENTS ATTENDING HEALTH CENTRES IN TRINIDAD

southwest Trinidad showed the prevalence of depression to be 28% among all patients and 30.2% among patients over 60 years of age [18]. This study did not specifically set out to study depression in the elderly however, and although 356 persons were over 60, we are not given any further analysis of this subgroup.

This study aims to establish the prevalence of depression in the elderly and its associated factors in order to make clinicians more alert to the possibility of depression lurking among their elderly patients and to dispel the myth that depression is a normal part of ageing. With proper diagnosis and appropriate treatment, the lives of the elderly depressed can be significantly improved allowing them to continue their valuable contribution to families, communities, and society.

Methods This was a cross sectional descriptive study. Convenience sampling of elderly patients at the Arima, St. Joseph, Freeport and Couva health centres was used to obtain the sample population over a three week period.

Instrument used – An interviewer applied modified Zung scale was used to assess each patient’s depression status. The Zung scale is a self-rating depression scale used primarily as a screening tool for depression [21]. For this study, a cut-off point of 60 was used, thus a patient was determined to be depressed if they scored 60 or higher on the Zung scale. Using a cut off score of 60, the Zung scale is 94% specific and 60% sensitive [18,19].

certain demographic data including gender, ethnicity, marital status, current living arrangement, current employment, level of education, presence of certain chronic illnesses. Participants were not asked their reason for health center attendance that day (eg. regular check up, particular complaint or even accompanying relative). No medical treatment or counseling was offered to participants that appeared to be significantly depressed during the interview.

The data collected was entered and analyzed using SPSS for windows version 10.0. Descriptive statistics were determined and Chi-square analysis was used to determine whether associations existed between depression status and demographic factors such as gender, ethnicity, marital status, current living arrangement, current employment, level of education, and presence of certain chronic illnesses.

Ethical considerations – Ethical approval was obtained from the ethics committee of the Faculty of Medical Sciences.

Results In this study 410 persons were invited to participate, 20 refused, giving a response rate of 95.1%. Of the remaining 390 respondents, 42 (10% of respondents) were excluded because of incomplete questionnaires.

Of the 348 persons who were included in the analysis, 75 (21.6%) were from Arima, 75 (21.6%) from St. Joseph, 93 (26,7%) from Freeport and 105(30.2%) from Couva.

The demographics of the sample are shown in Table 1.

Demographic data and basic health information was obtained using a questionnaire conceived de novo, which was pre-tested amongst a smaller random sample of elderly persons to ensure validity .Data collected included gender, ethnicity, marital status, current living arrangement, current employment, level of education and presence of certain chronic illnesses.

Sample Size Sample size was estimated at 401 based on the previous paper which suggested a prevalence of 30% (18) and with a precision of +/- 4% and 5% significance level and a non-response rate of 8%.

Recruitment of patients – Convenience sampling of consecutive patients at the above mentioned public health centres over a 3 week patient was used to obtain the sample. Patients were approached in the waiting areas of the clinics and were informed of the nature of the study and asked if they would be willing to participate. They were assured that notes would be kept confidentially and their decision to participate or not would not affect the type of service to which they were accustomed. Those willing to participate were interviewed discreetly in a secluded area of the waiting room as no private room was available.

Only patients 60 years and older were included. Among these, persons with significant communication problems eg. Advanced Alzheimer’s disease; patients with diagnosed dementia, bipolar disorder or schizophrenia were excluded as well as previous responders.

Participants were asked to respond to each item on the Zung scale and their scores recorded. They were also asked to provide 2

The majority of patients were 60 -79 years (90.8%), while 9.1% were 80 years or older. There were 200 females(57.4%) and 148 males(42.6%). Those of Indian descent made up 60.1%, those of African descent, 31.2% and mixed or other was 30 patients (8.7%). Almost equal numbers were in a relationship (49.1%) vs unattached (50.9%) and most lived with family (78.7%) vs. living alone. 267 had primary level education or none (76.7%); 58 had up to secondary level education and only 10 had a tertiary level education.

Chronic illnesses included HTN, DM, OA, cerebrovascular disease, Thyroid disease, IHD, Asthma and erectile dysfunction.

Hypertension was the most common chronic disease amongst the group, 63.8 %, followed by osteoarthritis (47.1%), and DM the 3rd most common Chronic disease (45.3%) see fig 2. Sixty patients (17.2%) had all 3 of the most common chronic illnesses (HTN, DM and OA).

Of the 348 persons, 60 were found to be depressed ie. scored 60% or more on the modified Zung scale and 288 were not depressed according to the Zung scale giving the prevalence of depression to be 17.2%.

Chi-square analysis was used to determine statistically significant associations between depression and the different demographic variables. Chi-square analysis indicated a significant relationship between level of education and depressed state (p=0.016). The respondents with no or primary education demonstrated the highest proportion of depression (43.8%), 26.0% of those who attained secondary level education were depressed and 1 out

Caribbean Medical Journal THE PREVALENCE OF DEPRESSION AND ITS ASSOCIATED FACTORS AMONG ELDERLY PATIENTS ATTENDING HEALTH CENTRES IN TRINIDAD

of the 9 persons who attained tertiary level education was depressed (11%). Age, gender, ethnicity, marital status, living arrangement and occupation all showed no significant association with being depressed.

Tests of association were examined against depression and presence of any chronic disease (any of the above); depression and the presence of all main chronic diseases(HTN, DM, OA) and between each of diseases and the presence of depression.

The presence of any chronic illness showed no significant relationship with being depressed (p=0.802). Of the depressed group 90% suffered from at least 1 chronic illness. Of the nondepressed group, 88.9%, an almost equal proportion, suffered from at least 1 chronic illness. The presence of all of the main chronic illnesses (HTN, DM, OA) showed no significant relationship with depression status (p=0.613). There was no statistically significant association between depression and the presence of any particular chronic disease. The depressed group demonstrated a significantly greater (p=0.023) proportion of asthmatics (20%) as compared to the non-depressed group (9.7%). Forty three percent (43.3%) of the 60 depressed persons did suffer from OA, but this was not significant at the 0.05 level.

Table 1 : Sociodemographic profile of the elderly respondents (N=348) from the four health centres visited during the period April-May 2005 and results of chi-square analysis.

Variable

Age 60-69 years 70-79 years 80 years and over

Depressed n(%) Not depressed N=60 n(%) N=288

Total

p- value

37(61.6) 16(26.6) 7(11.8)

163(56.6) 100(34.7) 25(8.7)

200 116 32

0.434

Gender Female Male

37(61.7) 23(38.3)

163(56.6) 125(43.4)

200 148

0.470

Ethnicity* Indian African Other+

37(62.7) 16(27.1) 6(10.2)

171(59.6) 92(32.0) 24(8.4)

208 108 30

0.724

Marital Status Married Unattached

23(38.3) 37(61.7)

148(51.4) 40(48.6)

171 177

0.066

0.059

Living Arrangement* Living alone Living with family

17(28.8)

51(18.0)

68

42(71.2)

232(82.0)

274

Occupation Working Not working

5(11.9) 52(88.1)

28(9.9) 255(90.1)

33 307

0.794

0.016

Level of education* No education Primary level Secondary level

16(28.1) 28(49.1)

36(12.9) 187(67.3)

52 215

12(21.1)

46(16.6)

58

Tertiary level

1(1.7)

9(3.2)

10

* Non-respondents * 3 depressed patients gave no response together with 10 non-depressed patients to the question concerning level of education * 1 depressed and 1 non-depressed patient did not have a recorded ethnicity * 1 depressed and 5 non-depressed patients had no response for living arrangement * 3 depressed and 5 non-depressed patients had no response for Employment status + Other is equivalent to 2 Chinese and 28 Mixed patients

Discussion The prevalence of depression in this elderly population was found to be 17.2%. This is comparable with international studies where the prevalence of clinically significant depressive symptoms ranges from approximately 13 – 18% [3, 22-25].

The prevalence of depression in the general population is estimated to be between 2-5% internationally [3,5,22,26]. The higher prevalence rate of depression in the elderly is probably multi-factorial – older persons have higher rates of chronic diseases, including those that are functionally limiting and/or painful such as arthritis. Many studies indeed do show a relationship between chronic illness, chronic pain, functional limitations and depression [3,5,26,27]. Locally, a study by Maharaj et al showed the prevalence of depression among patients attending chronic disease clinics to be 28.3% [18].

Many older persons face socio-economic challenges such as loneliness, reduced income with retirement that could also contribute to depressed mood. A study by Beekman et al shows consistent evidence for higher rates of depression among older people living under adverse socio-economic circumstances [25].

The relationship between depression and level of education was the only one which was found to be statistically significant in this study (p=0.016 ).This relationship between depression and lower levels of education is overwhelmingly reflected in many other studies both internationally and locally [18,23,26].

In our study, the majority of patients had primary level education or none (76.7%). For many, during the time, it was feasible only to continue education up to the primary level due to economic and cultural factors as well as overall inaccessibility.

Needless to say, lower education means probable lower income, poorer housing and amenities, tendency to be more vulnerable to negative life circumstances as well as tendency to be less informed about various risk factors, less likely to seek and follow treatment.

Interestingly, this study found no statistically significant association between the presence of any chronic disease and depression. This is not consistent with other data which indicates that patients who have chronic illnesses or suffer from chronic pain have a higher prevalence of depression [3,5,18,22].

An international survey shows that an average of between 9·3% and 23·0% of participants with one or more chronic physical disease had co-morbid depression - a result which was significantly higher than the likelihood of having depression in the absence of a chronic physical disease (p<0·0001) [5].

Although no statistically significant relationship between OA and depression was found, 43.3% of the 60 depressed persons did suffer from OA. In adult arthritis patients with co-morbid depression, improved depression care extended beyond reduced depressive symptoms and included decreased pain as well as improved functional status and quality of life [27].

With respect to the management of chronic diseases, depressive symptoms play an important role. The negative effects of depression on memory, attention, decision making abilities and the performance of more complex tasks are undisputed. All of these cognitive mechanisms play a key role in patient compliance.

For example, serious deficiencies in the decision to seek medical

3

Caribbean Medical Journal THE PREVALENCE OF DEPRESSION AND ITS ASSOCIATED FACTORS AMONG ELDERLY PATIENTS ATTENDING HEALTH CENTRES IN TRINIDAD

attention or call an ambulance have been reported in cases of slow onset asthma attacks in depressed patients [28].

This paper provides evidence of the prevalence of depression in the elderly population in Trinidad. This information has been extensively studied internationally and the links of depression and vascular disease has been made. It is thought that the link is bi-directional- depression leads to vascular disease and vascular disease leads to depression. Biological mechanisms have been blamed for these including cytokines, the hypothalamus pituitary adrenal (HPA) axis, and endothelial function [29]. The aim of this study is to provide some preliminary data on depression in the Trinidadian elderly population thus paving the way for future researchers that may wish to explore specific issues of depression in the elderly.

Ultimately clinicians caring for this population would have a better understanding of its prevalence and associated risk factors, which should result in higher rates of detection and effective treatment. The results would also be invaluable to health and social policy planners - if the factors associated with depression (eg. Poor education, insufficient income, poor housing) could be modified and resources allocated accordingly, the burden of depression could probably even be reduced.

It is possible that depressive symptoms are not perceived as medically important, but just ‘a normal part of the ageing process’ and that individuals will not seek treatment for these symptoms. These health beliefs could be explored in further studies and determine if indeed depression is being under reported and under diagnosed in the elderly population.

Limitations of this study Patients were selected by convenience sampling, not stratified random sampling and therefore it cannot be certain that our sample was representative of the elderly population of Trinidad.

Due to the limited time for data collection of three weeks, the calculated required sample size (N=401) was not achieved.

Another study with a larger sample size may be able to demonstrate statistically significant associations that were expected but not found in this study. (e.g. The association between chronic disease and depression) Conclusion As our elderly population continues to increase, it is important to address the mental health issues facing this group and to acknowledge the importance of their role in family life and society.

The prevalence of depression in the elderly was found to be 17.2%, which is comparable to international studies. It was found that level of education was associated with depression, also previously well documented. Gender, marital status, ethnicity and presence of medical co-morbidities were not found to be associated with depression in this study. Hopefully, this study can be used as a platform from which further studies on this subject can be launched so as to gain a better understanding of depression and its effects in the elderly. This in turn can lead to an improvement in preventative strategies, detection rates and effective treatment.

Competing interests: None declared 4

REFERENCES 1. Mid Year Population Estimates 2000-2010.The Central Statistical Office, Ministry of planning and development, The Government of Trinidad and To b a g o . R e t r i e v e d o n N o v e m b e r 9 2 0 1 1 , f r o m http://www.cso.gov.tt/statistics/Pages/details.aspx?category=Population% 20Statistics 2. Report of the Caribbean Symposium on Population Ageing.8-10 November 2004. Retrieved on November 9 2011 from h t t p : / / w w w. e c l a c . o rg / p u b l i c a c i o n e s / x m l / 8 / 2 2 4 3 8 / L . 0 4 1 . p d f 3. Katon W, Sullivan M D. Depression and chronic medical illness. Journal of Clinical Psychiatry 1990; 51(6, Suppl): 3-11.

4. Moussavi S, Chatterji S, Verdes E, Tandon A, Patel V, Ustun B. Depression, chronic diseases, and decrements in health: results from the World Health Surveys. The Lancet 2007; 370 (9590): 851-858.

5. Rawlins JM, Simeon DT, Ramdath DD, Chadee DD.The Elderly in Trinidad: Health, Social and Economic Status and Issues of Loneliness. West Indian Med J 2008; 57 (6): 589 6. Stewart WF, Ricci JA, Chee E, Hahn SR, Morganstein D. Cost of lost productive work time among US workers with depression.

JAMA.2003;289(23):3135-3144.

7. Scott J, Dickey B. Global burden of depression: the intersection of culture and medicine. The British Journal of Psychiatry 2003;183:92-94.

8. Raj D. Depression in the elderly : tailoring medical therapy to their special needs. Postgrad Med 2004; 115(6): 26-42.

9. Burke AW: Attempted suicide in Trinidad and Tobago. West Indian Med J 1974; 23:250-5.

10. Burke AW: Clinical aspects of attempted suicide among women in Trinidad and Tobago. Br J Psychiatry 1974, 125:175-6.

11. Burke AW: Socio-cultural aspects of attempted suicide among women in Trinidad and Tobago. Br J Psychiatry 1974, 125:374-7 12. Hutchinson G, Daisley H, Simmons V, Gordon AN: Suicide by poisoning.

West Indian Med J 1991, 40:69-73.

13. Hutchinson GA, Simeon D: Suicide in Trinidad and Tobago: associations with measures of social distress. Int J Soc Psychiatry 1997,43:269-75.

14. Neehall J, Beharry N: Demographic and clinical features of adolescent parasuicides. West Indian Med J 1994, 43:123-6.

15. Ali A, Maharajh HD: Social predictors of suicidal behaviour in adolescents in Trinidad and Tobago. Soc Psychiatry Psychiatr Epidemiol 2005, 40:18691.

16. Maharajh H, Ali A: Adolescent depression in Tobago. Int J Adolesc Med Health 2004, 16(4):337-42.

17. Maharaj RG, Roopnarinesingh N, Alli F, Cumberbatch K, Laloo P, Mohammed S, Ramesar A, Rampersad N, Ramtahal S: The prevalence of depression among secondary school students in Trinidad aged 13–19, May–June 2003. West Indian Medical J 2008;57(4):352-9.

18. Maharaj RG, Reid SD, Misir A, Simeon DT. Depression and its Associated Factors among Patients Attending Chronic Disease Clinics in Southwest Trinidad. West Indian Med J 2005; 54 (6): 369.

19. Maharaj RG. Depression and the nature of Trinidadian family practice : a cross-sectional study.BMC Family Practice 2007, 8:25 20. Maharaj RG. The Zung Scale in the management of fatigue in Trinidadian family practice patients. Caribbean Med J 2001; 63:20–5.

21. Zung WW, Richards C, Short M. Self rating depression Scale in an Outpatient Clinic. Arch Gen Psychiatry. 1965;13(6):508-515.

22. Katon W, Schulberg H. Epidemiology of depression in primary care. General Hospital Psychiatry. Volume 14, Issue 4, July 1992, Pages 237-247.

23. Barcelos-Ferreira R, Lopes MA,Nakano EY, Steffens DC, Bottino CM. Clinical and sociodemographic factors in a sample of older subjects experiencing depressive symptoms. Int J Geriatr Psychiatry. Oct 12 2011, doi:10.1002/gps.2803.[Epub ahead of print] 24. Murrell, S. A., Himmelfarb S, Wright K. Prevalence of depression and its correlates in older adults. Am J Epidemiol 1983; 117: 173–85.

25. Beekman AT, Copeland JR, Prince MJ. Review of community prevalence of depression in later life. The British Journal of Psychiatry 1999; 174 : 307-311.

26. Blazer D, Kessler R, McGonagle K, Swartz M. The prevalence and distribution of major depression in a national community sample: the National Comorbidity Survey. Am J Psychiatry 1994; 151:979-986.

27. Lin E et al. Effect of improving depression care on pain and functional outcomes among older adults with arthritis. JAMA.2003;290(18):24282429.

28. Goldney RD, Ruffin R, Fisher LJ, Wilson DH. Asthma symptoms associated with depression and lower quality of life: a population survey. MJA 2003; 178(9): 437-441.

29. Baune B T, Stuart M, Gilmour A, Wersching H, Heindel W, Arolt V, Berger K. The relationship between subtypes of depression and cardiovascular disease: a systematic review of biological models. Transl Psychiatry. 2012 March; 2(3): e92.

Caribbean Medical Journal

Original Scientific Article Is it time to replace 24-hour urinary albumin excretion (UAE) assessment in Trinidad and Tobago?

B Shivananda Nayak 1MSc PhD, Kameel Mungrue2 MPH & Boris Mohammed 3 MD MSc 1

Department of Preclinical sciences, Faculty of Medical Sciences, the University of the West Indies, Department of Paraclinical Sciences, Faculty of Medical Sciences, the University of the West Indies, 3 Department of Nephrology, the North Central Regional Health Authority, Trinidad 2

ABSTRACT Objective The aim of this study is to compare albuminuria measured by the conventional 24-hour urine collection and by spot urine albumin and by determining ACR, in a spot sample of urine.

Methods A first morning spot sample and 24 hour urine samples were collected from 64 subjects, irrespective of the prevailing pathology.

The urinary albumin and creatinine in both the spot and 24 urine samples was analyzed using the fully automated chemistry analyzer.

Results Of the 64 participants studied the 24 hour albumin varied from 30-3000 gm, the interquartile range 450-2814 gm. The sensitivity and specificity of the spot urine sample was 81.3% (95% CI 70.991.7) and 83.3% (95% CI 76.6-92).

Conclusions ACR did not provide any advantage over microalbumin measurement alone and in fact there was satisfactory agreement between the two measurements. ACR in addition requires a higher laboratory effort therefore in a low resource setting microalbumin measurement alone is the more convenient screening method in routine clinical practice especially in the developing world.

the excretion of 1-3 g/day of albumin derived fragments in combination with less than 25 mg/day of intact albumin (10, 11) with overall albumin excretion of approximately 2-4 g/day (10).

Thus by definition a urinary albumin excretion rate (AER) of <30 micrograms per minute (µg/min) is considered normal (normoalbuminuria), an AER between 30-299 microalbuminuria a marker for disease and an AER ≥ 300 µg/min macroalbuminuria.

Thus albumin: creatinine ratio should be >2.5 mg/mmol (men) or >3.5 mg/mmol (women) or albumin concentration >20 mg/l (12).

Epidemiological and experimental data show that high levels of urinary albumin excretion (UAE) are associated with an increased incidence of all-cause mortality and in particular cardiovascular (CV) mortality. This evidence comes from observations involving high-risk patients, such as those with diabetes and hypertension and the elderly, especially with existing CV disease (13-20).

Cardiovascular disease is the leading cause of death in Trinidad and Tobago with both hypertension and diabetes as major contributing comorbidities. Thus albuminuria is an important marker for assessment in both CV and non-CV diseases in the general population (21). Cardiovascular risk-factors also increase UAE (22), thereby creating a vicious cycle. Clinical assessment for microalbuninuria has been strongly advocated and necessary in our setting.

Key words: Urinary albumin, Spot urine, 24 hour urine sample Introduction The passage of albumin from the blood to urine and back is a complex process which begins with glomerular filtration. The quantity of albumin filtered is much more extensive than previously believed. As such, albuminuria appears to originate from processes that occur post-filtration, that is, as a result of abnormal processing of the filtered albumin by the tubular epithelial cells.

Two major cellular pathways controlling the processing of glomerular-filtered albumin distal to the glomerular basement membrane have been described: the degradation pathway and the retrieval pathway. Most of the filtered albumin is taken up by the retrieval pathway and returned to the blood supply. The small amount of albumin not taken up by the retrieval pathway is destined for excretion through the degradation pathway. The degradation pathway is a high affinity;low capacity pathway transporting relatively lower concentrations of albumin to lysosomes of the tubular cells. Once degraded, albumin is exocytosed into the tubular lumen and excreted in urine. The degradation pathway has been demonstrated to be responsible for microalbuminuria due to alterations in the balance of intact and degraded forms of albumin that are excreted (1-6). Also in nephrotic states the degradation pathway is inhibited (7-9).

Normal albumin excretion in humans is now recognized to involve

The "gold standard" to assess albuminuria is a 24-hour urinary albumin excretion (UAE). Because 24-hour urine collection is cumbersome, and presents additional challenges in the developing world, an alternative is to measure albuminuria in a first morning void, either as urinary albumin concentration (UAC) or adjusted for creatinine concentration, the albumin:creatinine ratio (ACR).

Measuring ACR in a first-morning-void urine sample is a good alternative to measuring 24-hour UAE (23). .

The aim of this study is to compare albumin measured by the conventional 24–hour urine collection with ACR among patients attending a tertiary teaching hospital.

Materials and Methods Sample collection and analysis Participants for the study were recruited from clients attending the Eric Williams Medical Sciences Complex (EWMSC) a 350 bed teaching hospital attached to The University of the West Indies. The 24 hour urine samples were collected from 64 subjects, irrespective of the prevailing pathology, as the aim of the study is to identify any relationship between 24 hr urine protein and ACR, in our setting. This approach would provide a wider range of values for analysis. After participants were instructed both by verbal and written instructions on the collection 24 hour urine 5

Caribbean Medical Journal IS IT TIME TO REPLACE 24-HOUR URINARY ALBUMIN EXCRETION (UAE) ASSESSMENT IN TRINIDAD AND TOBAGO?

the samples were collected. The volume of the 24 hour urine sample was recorded and refrigerated at 4°C until analysis.

A spot sample of urine was obtained by using the first morning urine sample during the 24 hour urine collection. Centrifugation of both the spot and the 24 urine remaining samples were frist performed prior to analysis to remove particulate matter. The urinary albumin in both the spot and the 24 urine samples was analyzed using the VITROS 950 a fully automated chemistry analyzer (Ortho diagnostics). Prior to analysis diluted 1 part of the original urine sample with 2 parts of reagent –grade water for a 3-fold dilution. At the end we multiplied the results by 3 to obtain an estimate of the urine albumin concentration. We calculated and expressed the results for 24 hour urine sample per volume and also per 100 ml to facilitate the comparison of spot sample with the 24 hour urine sample. The urinary creatinine in both the spot sample and 24 urine samples were analyzed using the VITROS 950 fully automated chemistry analyzer (Ortho diagnostics). Prior to analysis diluted 1 part of the original urine sample with 20 parts if reagent-grade water. At the end we multiplied the results by 21 to obtain an estimate of the urine creatinine concentration. Approval for the study was obtained from the University of the West Indies Ethics Committee.

Statistical methods All analyses were conducted using SPSS version 16. Results are reported as mean and SD unless otherwise specified. Diagnostic performance is expressed in terms of specificity and sensitivity and areas under the receiver operating characteristic (ROC) curves. The agreement of spot urine samples and twenty four urine samples was also evaluated using the Kappa statistic, the measurements were divided into pathological and normal samples.

The cut-offs used for this stratification were as follows: (1) 30mg/dL for the microalbumin measurements in the spot urine; (2) 30 mg/24hr for the microalbumin measurements in the 24hr urine; and (3) 3mg/mmol for ACR. Regression analysis and Spearman Rank Correlation test was used to evaluate the relationship of microalbuminuria in the spot urine and 24-h urine samples. A p value of <0.05 was regarded to indicate statistical significance.

Results Sixty four (64) patients were included in the study, there were 40 males and 24 females. None of the patients had to be excluded due to heavy exercise during the collection period. To evaluate the diagnostic performance of the albumin measurements in the spot urine sample pathologic microalbuminuria was assumed when the microalbumin concentration exceeds 30 mg/24-h, in the 24-h urine sample. Thus 24-hour urine was used as the gold standard to confirm the presence of microalbuminuria. Of the 64 participants studied the 24 hour albumin varied from 30-3000 gm, the interquartile range was 450-2814 gm. The sensitivity and specificity of the spot urine sample for albumin was 81.3% (95% CI 70.9-91.7) and 83.3% (95% CI 76.6-92).

The diagnostic performance of the albumin measurements in the spot urine sample expressed as the area under the ROC curve was 0.87 (95% CI 0.81-0.95). Similarly the sensitivity and specificity of the ACR of the spot urine sample were 90.1 % ( 95% CI 84.1-96.1) and 85.2 %( 95% CI 76-94.4%) respectively.

The overall diagnostic performance of the ACR of the spot urine sample expressed as the area under the ROC was 0.94 (95% CI 0.89- 0.97) (Fig1).

6

Fig 1: The relationship between the Ln of the 24 urine albumin and ACR.

The diagnostic performance of ACR was not significantly different from the crude microalbuminuria measurement in the spot urine. (p=.325). In addition the Kappa statistic was 0.76 for agreement between ACR and spot urine protein.

Discussion All 64 participants in the study had a 24hr urine albumin assessment performed. The presence of albumin was detected in all participants and varied between 30-3000 gm. We then assessed albumin and creatinine in the spot sample, and using the 24 hr urine assessment as our gold standard we showed that the sensitivity and specificity for albumin in the spot sample was 81.3% and 83.3% respectively and the area under the ROC curve was 0.87. On the other hand using ACR the sensitivity and specificity improved albeit not significantly to 90.1% and 85.2% respectively and the area under the ROC was 0.94. In fact there was satisfactory agreement between albumin measured in the spot urine with ACR. However evidence suggest that ACR is the preferred method of screening for microalbumin as 24-hr or timed collections are more burdensome and add little to prediction or accuracy [24-25]. Our study demonstrated a good correlation between albuminuria measured as ACR and separately compared with 24-hr measurements, a finding consistent with others [2628]. In fact the small improvement in both sensitivity and specificity using ACR may have little clinical impact. Chronic kidney disease has reached epidemic proportions in Trinidad, it is frequently unrecognised and often exists together with other conditions for example, cardiovascular disease, hypertension and diabetes. If allowed to advance, it is associated with a higher risk of mortality but more importantly can progress to renal failure in a significant percentage of people in our setting.

Currently the burden is so great that the state cannot provide sufficient renal dialysis centers to cope and now offers a monthly grant of $5000.00 (TT$) to support patients needing to have dialysis, in the private health care setting . In addition CKD is usually asymptomatic, but can be detectable, using tests that are both simple and freely available at the level of primary health care facilities in Trinidad. Treatment can prevent or delay the progression of CKD, reduce or prevent the development of complications and reduce the risk of cardiovascular disease.

However, because of a lack of specific symptoms people with CKD are often not diagnosed, or diagnosed late when CKD is at an advanced stage. Further using the US ‘National Kidney Foundation kidney disease outcomes quality initiative’ (NKF-

Caribbean Medical Journal IS IT TIME TO REPLACE 24-HOUR URINARY ALBUMIN EXCRETION (UAE) ASSESSMENT IN TRINIDAD AND TOBAGO?

KDOQI) CKD can be classified into five stages. Stages 3–5 may be defined by glomerular filtration rate (GFR) alone, whereas stages 1 and 2 also require the presence of persistent proteinuria, albuminuria or haematuria, or structural abnormalities, hence the relevance and need for this study.

A major limitation of the study is the impact of a screening test has to be evaluated with regard to the prevalence of the disease in the population. The prevalence of CKD in our population is unknown, although presumed high, we therefore assume that our results are clinically relevant.

In summary ACR did not provide any advantage over microalbumin measurement alone and in fact there was satisfactory agreement between the two measurements. ACR in addition requires a higher laboratory effort therefore in a low resource setting microalbumin measurement alone is the more convenient screening method in routine clinical practice especially in the developing world.

10.

11.

12.

13.

14.

15.

16.

17.

18.

Acknowledgements Authors wishes to thank all the technicians of the diagnostic laboratory at Eric Williams Medical Sciences complex

19.

Competing interests None declared

20.

*Author for Correspondence: Dr.Shivananda Nayak, Department of Preclinical Sciences, Faculty of Medical Sciences The University of the West Indies, St. Augustine, Trinidad.

Tel/Fax: 1-868-662-1873, E-mail: shivananda.nayak@sta.uwi.edu

21.

REFERENCES 1. Gudehithlu KP, Pegoraro AA, Dunea G, et al. Degradation of albumin by the renal proximal tubule cells and the subsequent fate of its fragments. Kidney Int. 2004; 65:2113-2122.

2. Osicka TM, Pratt LM, Comper WD. Glomerular capillary wall permeability to albumin and horseradish peroxidase. Nephrology. 1996; 2:199-212.

3. Greive KA, Nikolic-Paterson DJ, Guimarães MAM, et al. Glomerular permselectivity factors are not responsible for the increase in fractional clearance of albumin in rat glomerulonephritis. Am J Pathol. 2001; 159:11591170.

4. Osicka TM, Strong KJ, Nikolic-Paterson DJ, et al. Renal processing of serum proteins in an albumin-deficient environment: An in vivo study of glomerulonephritis in the Nagase analbuminaemic rat. Nephrol Dial Transplant.

2004;19:320-328.

5. Russo LM, Bakris G, Comper WD. Renal handling of albumin. A critical review of basic concepts and perspective. Am J Kidney Dis. 2002;39:899919.

6. Hilliard LM, Osicka TM, Clavant SP, et al. Characterisation of the urinary degradation pathway in the isolated perfused rat kidney. J Lab Clin Med. 2006; 147:36-44.

7. Burne MJ, Panagiotopoulos S, Jerums G, et al. Alterations in renal degradation of albumin in early experimental diabetes in the rat: A new factor in the mechanism of albuminuria. Clin Sci. 1998; 95:67-72 8. Osicka TM, Comper WD. Protein degradation during renal passage in normal kidneys is inhibited in experimental albuminuria. Clin Sci. 1997; 93:65-72 9. Osicka TM, Hankin AR, Comper WD. Puromycin aminonucleoside nephrosis

22.

23.

24.

25.

26.

27.

28.

results in a marked increase in fractional clearance of albumin. Am J Physiol.

1999;277:F139-F145.

Greive KA, Balazs ND, Comper WD. Protein fragments in urine have been considerably underestimated by various protein assays. Clin Chem. 2001; 47:1717-1719 Osicka TM, Houlihan CA, Chan JG, et al. Albuminuria in patients with type 1 diabetes is directly linked to changes in the lysosome-mediated degradation of albumin during renal passage. Diabetes. 2000;49:1579-1584.

American Diabetes Association, Standards of Medical Care in Diabetes— 2010 Diabetes Care. 2010; 33:S11-S61] Rossing P, Hougaard P, Borch-Johnsen K, et al. Predictors of mortality in insulin dependent diabetes: 10 year observational follow up study. BMJ. 1996; 313: 779–784.

Jager A, Kostense PJ, Ruhe HG, et al. Microalbuminuria and peripheral arterialdisease are independent predictors of cardiovascular and all-cause mortality, especially among hypertensive subjects: five-year follow-up of the Hoorn Study. ArteriosclerThrombVascBiol.1999; 19:617–624.

Damsgaard EM, Froland A, Jorgensen OD, et al. Microalbuminuria as predictor of increased mortality in elderly people. BMJ.1990; 300: 297–300.

Dinneen SF, Gerstein HC. The association of microalbuminuria and mortality in non insulin-dependent diabetes mellitus: a systematic overview of the literature. ArchInternMed.1997; 157:1413–1418.

Yudkin JS, Forrest RD, Jackson CA. Microalbuminuria as predictor of vascular disease in non-diabetic subjects: Islington Diabetes Survey. Lancet. 1988; 2: 530–533.

Roest M, Banga JD, Janssen WM, et al. Excessive urinary albumin levels are associated with future cardiovascular mortality in postmenopausal women.

Circulation.2001; 103:3057–3061.

Borch-Johnsen K, Feldt-Rasmussen B, Strandgaard S, et al. Urinary albumin excretion: an independent predictor of ischemic heart disease. Arterioscler Thromb VascBiol.1999; 19:1992–1997.

Gerstein HC, Mann JF, Pogue J, et al. Prevalence and determinants of microalbuminuria in high-risk diabetic and nondiabetic patients in the Heart Outcomes Prevention Evaluation Study: the HOPE Study Investigators.

Diabetes Care. 2000; 23 [suppl 2]: B35–B39.

Hans LH, Vaclav F, Gilles FH Diercks, Wiek H van Gilst, Dick de Zeeuw, Dirk J. van Veldhuisen, Rijk OB Gans, Wilbert MT Janssen, Diederick E Grobbee,Paul E.de Jong., for the Prevention of Renal and Vascular End Stage Disease [PREVEND] Study Group. Urinary Albumin Excretion Predicts Cardiovascular and Noncardiovascular Mortality in General Population.

Circulation. 2002;106:1777-1782.

Solbu MD, Kronborg J, Eriksen BO, Jenssen TG, Toft I. Cardiovascular riskfactors predict progression of urinary albumin-excretion in a general, nondiabetic population A gender-specific follow-up study. Atherosclerosis. 2008 Mar 6 Hiddo J, Lambers Heerspink, Auke H. Brantsma, Dick de Zeeuw, Stephan J. L. Bakker, Paul E. de Jong, Ron T. Gansevoort and for the PREVEND Study Group. Albuminuria Assessed From First-Morning-Void Urine Samples Versus 24-Hour Urine Collections as a Predictor of Cardiovascular Morbidity and Mortality. Am J Epidemiol. 2008 Oct 15;168(8):897-905.

Eknoyan G, Hostetter T, Bakris GL, Hebert L, Levey AS, Parving HH, Steffes MW, Toto R. Proteinuria and other markers of chronic kidney disease: a position statement of the national kidney foundation [NKF] and the national institute of diabetes and digestive and kidney diseases [NIDDK]. Am J Kidney Dis 2003;42:617–622 Levey AS, Coresh J, Balk E, Kausz AT, Levin A, Steffes MW, Hogg RJ, Perrone RD, Lau J, Eknoyan G, National Kidney Foundation. National Kidney Foundation practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Ann Intern Med 2003;139:137–147 Rodby RA, Rohde RD, Sharon Z, Pohl MA, Bain PR, Lewis EJ, for the Collaborative Study Group. The urine protein to creatinine ratio as a predictor of 24-hour urine protein excretion in type 1 diabetic patients with nephropathy.

Am J Kidney Dis 1995:26:904-909.

James MA, Fotherby MD, Potter JF. Screening test for microalbuminuria in non-diabetic elderly subjects and their relation to blood pressure. Clin Sci 1995; 88:185-190.

Steunhauslin F, Wauters JP. Quantitation of protein in kidney transplant recipients: accuracy of the urine protein/creatinine ratio. Clin Nephrol 1995: 43:110-115.

7

Caribbean Medical Journal

Original Scientific Article Challenges of providing comprehensive clinical service within the public health sector: a case study of the Paediatric Oncology service Prof. Z. Ali 1,2 FRCPCH, A. Lum Lock2 MSc & C. Bodkyn1 MRCP(I) 1 Child

Health Unit, Faculty of Medical Sciences, The University of the West Indies, St. Augustine and Tobago Health Training Centre, Trinidad

2Trinidad

ABSTRACT Objective To assess the needs of the departments at the Eric Williams Medical Sciences Complex (EWMSC) which provide critical support to the paediatric oncology service.

Design and Methods Key members of staff actively involved in the delivery of paediatric oncology services at the EWMSC were surveyed using selfadministered questionnaires. Information sought was related to medical, operational, human resource, financial, administrative, infrastructural and psychosocial challenges in providing the service.

Results Twenty members of staff from six departments participated and reported priority challenges in human resources, operational and infrastructural areas in all six departments. Medical diagnostic, administrative and financial issues were high priority in four departments and social/psychological issues in the social work department.

Conclusion Human resources, infrastructural support of services and data management needs were identified as key challenges. Using a acombination of basic and novel approaches to overcome these challenges would lead to improved patient outcome.

Introduction The twin island Republic of Trinidad and Tobago is situated 7 miles from the northeast coast of Venezuela, South America and has a population of 1.3 million. The crude incidence rate of cancer for the period 2000-2002 was 138 per 100,000 person years (pyrs). Paediatric cancers accounted for less than 2% of these cases with leukaemia remaining a leading form of cancer in the 0-14 year age group [1].

The Government of the Republic of Trinidad and Tobago has expressed a strong commitment to developing the public health sector which fosters a multidisciplinary approach to patient care [2,3], including establishment of a comprehensive national oncology programme [4]. In June 2001 paediatric oncology service was centralised at the Eric Williams Medical Sciences Complex (EWMSC) and an average of about 30 new patients are treated per year, all of whom are within the 0-14 year age group. In 2009, a non-governmental organisation, the Just Because Foundation (JBF) partnered with local funding agencies to

8

refurbish a ward, the Just Because Foundation Specialty Unit (JBFSU), at the Wendy Fitzwilliam Paediatric Hospital to accommodate children diagnosed with cancer. A multidisciplinary team consisting of the paediatric oncologist, paediatric surgeons, radiologist, pathologist, radiation oncologist, social workers, pharmacist and nursing staff work closely to provide the patient with integrated and dedicated care. Optimal functioning of the respective departments represented as a multidisciplinary team is essential for effective service delivery. The objective of this survey was to assess the needs of six of the departments at EWMSC which provide critical support to the paediatric oncology service in order to improve service delivery.

Methods A self-administered questionnaire was designed to elicit information on the available services, resources and the challenges encountered by health providers in an effort to deliver quality service for the diagnosis, treatment, care and support to children diagnosed with cancer. The level of priority which respondents felt the issues or challenges should be given was requested using a Likert scale of 1 to 5 (1 being the lowest priority and 5 the highest). The information was collected according to the following categories: Medical: Equipment and supplies including drugs, length of time to obtain a diagnosis or treatment and patients loss to follow up (percentage of patients who withdraw prematurely from treatment Operational: Use of specific techniques and procedures, storage space, data collection, maintenance and retrieval, access to information and communication technology (ICT), computer hardware and software.

Human resources: Hiring and retention of trained and qualified staff, patient to staff ratio, staff to workload ratio, access to staff training and continuing education.

Financial: Funding challenges related to the conduct of research, operational issues and salaries.

Administrative: Organisational structure, interdepartmental communication, contractual arrangements, length of time for processing of documentation.

Infrastructural: Physical space, building design, building access, ventilation, staff work areas, telephone access, building service and maintenance.

Social Psychological: Patient interaction and communication, patient support and information.

Core members of the paediatric oncology multidisciplinary team were selected by convenience sampling and were invited to participate in the survey. Data were collected during the period 12-27 October, 2009 and were analysed using qualitative methods.

Caribbean Medical Journal CHALLENGES OF PROVIDING COMPREHENSIVE CLINICAL SERVICE WITHIN THE PUBLIC HEALTH SECTOR: A CASE STUDY OF THE PAEDIATRIC ONCOLOGY SERVICE

Results There were 20 respondents from the six departments which make up the multidisciplinary team caring for children with cancer (Table 1). This represents 83% of the health care workers at the EWMSC identified for the assessment. The challenges identified by the respondents were as follows (Table 2): Table 1. Respondents from departments at the EWMSC providing paediatric oncology services Department

Services contributing to patient care

Laboratory Radiology Surgery Pharmacy Nursing Social Work

Diagnostic Diagnostic Diagnostic and Treatment Treatment Care and support Support

No. of Respondents 8 3 5 2 1 1

TOTAL

20

Medical: Lack of important equipment, chronic shortages of basic supplies and consumables, extended equipment downtime for repairs, limited operating theatre time, insufficient intensive care bed space and stock-out of drugs.

Operational: Shortage of storage space, lack of processing laboratory, outdated fume cupboard, poor data management and information technology.

Human resources: Shortages and poor retention of staff resulting in a heavy workload and low staff morale.

Financial: Poor remuneration, inadequate funding for operational costs and research needs.

Administrative: Poor procurement practice, lack of communication between administration and technicians and lack of familiarity with the institutionâ&#x20AC;&#x2122;s organisational chart.

Infrastructural: Limited physical space for work and staff amenities together with poor access to communication within the departments and to provide patient support.

Table 2. Challenges identified by Staff from different departments at the EWMSC Types of Challenges Reported Service

Medical

Operational

Human Resource

Financial

Administrative

Infrastructural

Laboratory Haematology Microbiology Blood Bank Biochemistry Histopath

Lack of key equipment

Limited storage

Limited staff training

Poor salary scale = low morale

Poor procurement practice

More bench & office space

Heavy work load

AC not working

Lack of communication between administrative and technicians

Long down time for basic utilities

Shortage of basic supplies

Shortage of refrigerator No photocopier

Need for markers for immunohisto

Drs. Do not follow pre-testing protocol

Staff shortage Need data manager, technician for blood separation & consultant

No research

Radiology

Chronic shortage consumables Long equipment downtime

No MRI or CT (service breakdown)

Only 1 WC Locked fire escape exit

Heavy workload

-

Long equipment downtime

No internet service

Funds for Research and lab supplies

Better lines of communications between admin and other departments

More physical space

Poor salary scale = low morale

No organization chart

No AC

No training time

Record retrieval problems

No facility to sedate kids Surgery

Limited theatre time

Poor data access

Long wait for path report

No computer or internet

Insufficient ICU beds

Lack office space

Better communication with parents

Need processing lab

Problems with receiving drugs;

No internet, storage room

Stock-outs

Outdated fume cupboard

Nursing

Lack of ward monitors

No patient information system

More nurses and training needed

Social Work

-

Outdate computer No imternet Inadequate storage

Inadequate staffing

Pharmacy

More nurses in all areas Need data manager More pathologists needed

Better links with overseas experts Heavy workload No training time

Nursesâ&#x20AC;&#x2122; Lounge needed Poor salary scale = low morale

-

Need telephone, office space and security

9

Caribbean Medical Journal CHALLENGES OF PROVIDING COMPREHENSIVE CLINICAL SERVICE WITHIN THE PUBLIC HEALTH SECTOR: A CASE STUDY OF THE PAEDIATRIC ONCOLOGY SERVICE

Discussion The need for an increase in the number of staff was identified as a high priority in all six departments. Trinidad and Tobago face an ongoing shortage of qualified health care professionals with many migrating to the United States, United Kingdom and other Caribbean islands (3). Members of staff also felt that access to continuing professional education was lacking with low wages identified as a major issue in the social work, laboratory and pharmacy departments. These departments form the key support framework for effective patient-centred care. The constant demands on staff where understaffing is the norm, in addition to working in a mentally and physically demanding field, often lead to “burnt out syndrome”, highlighting the importance of having a support service catering for staff mental health. Ongoing training both in-house and through collaborative effort with international centres utilising distance learning methodologies can meet the challenge of physician isolation and the need for continuing professional education [5, 6].

Infrastructural issues were another high priority area identified across all departments. Prolonged downtime for repairs of equipment and limited telephone and internet access contributed to inefficiencies in service delivery as the ability to carry out departmental functions and have good interdepartmental and inter-institutional communication were affected. Administrative challenges can be addressed through regular meetings of multidisciplinary staff to communicate changes in service procedure and process, identify specific challenges and share updates.

The results of this study could be interpreted as advocating for efficiency and change in the public health sector. It identifies the need for staff to be appraised of the administrative structure including staffing norms, recruitment, deployment, career path development and continuing professional development of the institution. It speaks to the fact that staff needs to feel a sense of ownership and be appreciated and respected. The issues of infrastructure, procurement and maintenance of fixed assets and the assurance of continuous and reliable supply of consumable items which haunt the public sector must be addressed.

The paediatric oncology service is one example reflecting the bigger picture of the shortcomings in the public health sector. In order to move the services forward, a more in-depth assessment to solicit and examine key issues and priorities for improving the quality of service delivery needs to be conducted among the various departments contributing to health care. This will ensure “buy-in” by all stakeholders. This is not an easy task since the potential for conflict, paralysis or failure to move forward is always a possibility. Apart from manpower needs, the availability of data to inform decision-making is crucial. ICT has enormous potential as a tool to facilitate information flow, disseminate evidence –based knowledge and to empower the staff to ensure that the health care workers, the health system and the users of the system all benefit.

Acknowledgements We wish to thank The UWI Telehealth Programme for developing this project and the staff of the Eric Williams Medical Sciences Complex who participated in the assessment.

With the exception of the pharmacy, operational issues were of great concern. The main challenges were data management practices and expertise. The limited storage space available made the collection, storage, retrieval and analysis of service data and the conduct of service audits extremely difficult, if not impossible.

However, although data are currently paper based, there is a national plan to implement a patient information system and a complete integrated IT platform. In the interim, the staff suggested that existing protocols and procedures should be observed, including accurate labelling and registration of specimens and the completion of laboratory request forms giving patient information to assist in the performance of appropriate tests for the diagnosis of the patient.

Competing Interests None declared.

Although challenges identified are not unique to the services provided within the public health sector, provision of a basic acceptable service is heavily dependant on the use of functioning specialised laboratory equipment to support diagnosis and timely procurement of adequate supplies of consumables and reagents.

The laboratory staff identified a lack of patient data to assist them in conducting tests in a timely or efficient manner. It was also felt that clear definition of roles and interdepartmental communication was necessary to make a significant change in service delivery. This chronic problem may be due to management issues or may be directly linked to financial limitations on the service.

REFERENCES 1. The National Cancer Registry of Trinidad and Tobago. Cancer in Trinidad and Tobago 2000-2002. Dr. Elizabeth Quamina Cancer Registry. Undated.

2. Government of Trinidad and Tobago. Trinidad and Tobago health sector reform programme: National Health Services Plan. Annex 3; 1994 3. Pan American Health Organization. Health Systems Profile Trinidad & Tobago: Monitoring and Analyzing Health Systems Change/Reform, Third Edition (October 2008), Pan American Health Organization Health Systems Profile: Trinidad & Tobago. Washington, D.C.: PAHO, 2008 4. Government of Trinidad and Tobago. Functional programme for Trinidad and Tobago. National Oncology Centre, CCI Facilities Team; 2001 5. Dutta, PK, Jena, TK, SK Panda. A plea for health manpower training through distance education. Med Educ Online [serial online]. 1996. Retrieved from http://www.med-ed-online.org/f0000005.htm November 1 2011 6. Webb, MA. Interactive technology in healthcare education [Internet]. 2005.

Retrieved from http://www.roseindia.net/articles/interactive-technologyhealthcare.page November 1 2011.

10

Corresponding Author: Professor Zulaika Ali Professor of Child Health (Neonatology) Department of Clinical Medical Sciences.

The University of the West Indies Eric Williams Medical Sciences Complex Trinidad and Tobago Tel.: 868-620-8538 Telefax.: 868-662-9596 E-mail: zulaika.ali@gmail.com

Caribbean Medical Journal

Original Scientific Article Introduction of a Simulation Laboratory to Preclinical Students at St. George’s University in Grenada J.K. Rooney MD, K. Bourne-Yearwood MBBS, Frances McGill MD & T. J. McCann PhD St. George’s University, Grenada

ABSTRACT Objective To investigate the use of high fidelity simulation mannequins in improving competence and confidence levels of medical students to recognize cardiac and lung sounds.

Study design Observational study.

Subjects and Methods The students took a pre-test evaluating their ability to recognize cardiac and respiratory sounds. They then rotated through three clinical scenarios using simulation mannequins. They were then given a post-test. Both prior to, and following the session the students completed a Likert scale on their comfort in recognizing the sounds. The pre- and post-test scores were compared.

Results There was a significant improvement in the students’ ability to recognize cardiac and respiratory sounds (p<0.0001), as well as in their comfort levels (p<0.0001). Overall, 80% of the students felt more comfortable in their ability to recognize the sounds, 17% felt the same and 3% felt less comfortable.

Conclusions Use of simulation mannequins improves medical students’ abilities, as well as comfort in recognizing cardiac and respiratory sounds.

Introduction There are many approaches to using simulation in medical education. Simulation is defined as replacement of real patient encounters with either standardized patients or technologies that replicate the clinical scenario. Simulators include standardized patients, screen based computers, partial task simulators, and high fidelity mannequin simulators. Inanimate models and animal laboratories have been used to teach surgical skills to resident physicians and new skills to senior surgeons.

More recently high fidelity simulators with the capacity to interact with the human have been used, particularly in anesthesiology, critical care, emergency medicine training, and in cardiac life support [1].

All forms of simulation have value in providing student-centered education. This is a departure from the traditional approach of reliance upon real patients for medical education [2]. Simulation based medical education is currently used in many undergraduate medical settings. The advantages are numerous [3]. Medical students can learn skills and practice new procedures until comfortable and confident. The learner can react as he/she

would to a real patient. As hospital stays have become shorter, it has become more difficult to find available patients with unusual and clinically instructive conditions as needed for teaching.

Current best standards for medical education are to provide objective and constructive learning experiences which are easily done with simulation [4]. Repetition and practice of clinical skills permits learners to become competent at their own pace.

In today’s climate of patient safety and ethics of patient care, a simulated clinical environment provides a safe learning experience for students [4].

Studies have demonstrated that simulation in pre-clinical settings enhances competence in learning clinical skills [5], but to date the challenge has been to demonstrate that simulation based medical education will extend to better patient care [6]. While currently used in several residency settings (anesthesiology, surgery, emergency medicine and obstetrics/gynecology) the best ways to use simulation in basic sciences pre-clinical medical education has not been fully determined.

St. George’s University (SGU) has been educating medical students in the basic sciences since 1977 in the Caribbean region. The students then continue clinical training in either the United States or the United Kingdom. The background of the international student body is heterogeneous, ranging from students having no clinical medical experience to those with prior experience in medical research, nursing, pharmacy and emergency medicine. In recent years the class sizes have been increasing which has not directly impacted lectures but requires more effort in developing small group sessions.

Simulation is not new to SGU. SGU’s Standardized Patient Program was introduced in 1994 and has been used in the 4th term Communication and Physical Diagnosis course. Following this, students learn techniques of physical diagnosis by practicing on each other; however experience with patients is limited. In the 5th term there is more patient exposure in the Introduction to Clinical Medicine course through 10 hospital/clinic visits.

SGU has recently developed a Simulation Center in Grenada and the university has introduced a simulation session to all students in their 2nd year (5th term course, Introduction to Clinical Medicine) included as one hospital/clinic visit. The purpose of this study was to explore the use of simulation in a standard clinical setting to determine the following outcomes: 1) Integration of simulation sessions into clinical education with large numbers of students 2) Competence by pre- and post-scores of students in hearing cardiac and respiratory sounds 3) Comfort by pre- and post-scores of students in the simulation learning environment

11

Caribbean Medical Journal INTRODUCTION OF A SIMULATION LABORATORY TO PRECLINICAL STUDENTS AT ST. GEORGE’S UNIVERSITY IN GRENADA

Methods There were 509 students in the 5th term class who were required to rotate through the Simulation Laboratory (Sim Lab) as part of their Introduction to Clinical Medicine course. In order to accommodate the large number of students a strict and well planned schedule was put into place. The students were divided into approximately 88 groups of 6. Each group of students attended one 2.5 hour session in the Sim Lab. This was accomplished over a total of 8 weeks.

Prior to the start of these rotations, 18 physicians in the Teaching Fellow Program of the School of Medicine (SOM) received 2 hours of training to conduct the sessions. This included an introductory segment which addressed the use of mannequins/simulators in the teaching of medical students, a discussion on the format of the session, and a breakdown of the format for debriefing the students at the end of the session.

Following this each teaching fellow was trained how to operate the mannequins and given time to practice their new skills.

Case scenarios were written by faculty and refined after rehearsal with the teaching fellows. Each session was supervised by a full time clinical skills faculty (4 in total) as well as the directors of the Simulation Center.

Students were required to be professionally dressed for the session and also to display professional attitudes while in the laboratory. This included interacting with the mannequins and displaying appropriate bedside manner and communication skills. Upon arrival in the Sim Lab the students were given a brief introduction and informed of the proceedings of the lab.

Following the introduction the students were asked to complete a pre-test (Appendix 1). This pre-test consisted of asking the students to identify different cardiac and respiratory sounds played through speakers attached to a student auscultation mannequin (SAM). The same 7 sounds were played for all students: normal heart sounds, normal breath sounds, systolic murmur (aortic stenosis), diastolic murmur (mitral stenosis), stridor, wheezing, and crackles. Each of the sounds was played for 30-45 seconds. The students were informed that they would later have a post-test and that neither of their scores, either on the pre- or the post-test would contribute to their grade in the course.

Following completion of the pre-test, the students joined the members of their group and proceeded to one of three stations.

Laerdal mannequins (SimMan 3G and VitalSim) were preprogrammed with clinical signs and symptoms (Appendix 2).

A senior faculty member and the co-director of the Sim Lab were present at every session. A teaching fellow facilitated the scenario and patient interaction. At each bedside the students were initially given a brief history of the patient.

For example, “This patient is a 64 year old male who presented to the emergency department with shortness of breath and chest pain.

He has a history of intermittent chest pain upon exertion for the past 3 years. He had an episode of chest pain which was very severe 4 days ago, lasted 30 minutes and was associated with exertion. During this episode he also felt nauseated and sweaty. Over the past 4 days he has been becoming increasingly short of breath.”

12

Appendix 1 Introduction to Clinical Medicine Simulation Laboratory (Pre-Test) Name: Date: Please rate how well you feel that you can identify and recognize cardiac murmurs (Please circle one) 5 Extremely

4 comfortable

3 neutral

2 1 Not very Not comfortable comfortable at all

Please rate how well you feel that you can identify abnormal and adventitious breath sounds (please circle one) 5 Extremely

4 comfortable

3 neutral

2 1 Not very Not comfortable comfortable at all

Appendix 2 Sample Scenario Acute Myocardial Infarction with Congestive Heart Failure Preparation of Simulator Telemetry unit Mannequin in patient gown Nasal cannula in place and attached to oxygen source Patient to say “My chest is hurting me and I can’t breathe” Vitals: Heart rate: 132 beats/minute (rhythm normal, volume normal, contour normal) Respirations: 26 breaths/minute Blood pressure: 102/62 mm/Hg Temperature: 98.6o Fahrenheit SpO2: 93% on 2 L O2 via nasal canula Auscultation of heart: Normal S1, S2, no murmurs, no additional sounds Auscultation of lungs: rales (crepitations) heard Student Objectives 1. Evaluate the patient and perform an overall assessment of the patient (appearance, level of consciousness etc.)

2. Demonstrate appropriate patient interaction (obtaining history from patient and tutor) Perform patient assessment based on resources available at the bedside (chart, vital signs, SpO2 etc.)

3. Demonstrate appropriate hygiene techniques - wash hands 4. Obtain patient vitals (including all aspects – BP by palpation as well as auscultation, pulse – contour, volume etc.)

5. Perform a complete cardiovascular examination At this point the students were expected to ask for additional history. The information was provided either by the patient (mannequin using a set of programmed voice responses) or by the teaching fellow at the bedside. Once the history was completed the students moved on to perform the physical examination. This began with an overall assessment of the patient, followed by the vital signs and then examination of the

Caribbean Medical Journal INTRODUCTION OF A SIMULATION LABORATORY TO PRECLINICAL STUDENTS AT ST. GEORGE’S UNIVERSITY IN GRENADA

relevant system. Each of the mannequins had pre-programmed vital signs, respiratory and cardiac sounds. The facilitator could change the vital signs and any other sound during the session.

All students participated in the physical examination. The history and focused physical were only allocated a total of 10 minutes as the main goal of the session was to allow the students the opportunity to auscultate the mannequins (approximately 20 minutes). Following the physical examination the students were given the opportunity to listen to additional abnormal sounds (for instance at the station with aortic stenosis other heart murmurs were played and their characteristics explained by the facilitator). Each station ended with a facilitated discussion/debriefing.

After the students rotated at all 3 patient stations they then took the post-test. The pre- and post-tests were identical. Prior to both the pre- and the post-test each student was asked to rate their level of comfort in their ability to recognize cardiac sounds and respiratory sounds using a Likert scale. The scale ranged from 1-5 (extremely comfortable to not comfortable at all).

Their level of comfort on the pre-test was compared to their level of comfort on the post-test. The number of students who felt more confident, the same, or less confident was compared.

The scores on both the pre-tests and the post-tests were analyzed.

The number of correct answers in the pre-test was compared to the number in the post-test. Students who were missing values were not included in data analysis.

Results The pre- and post-tests, and comfort level Likert scales were given to 509 5th term medical students at SGU.

Figure 1: Average weekly scores of the pre- and post-tests

Competence Thirteen students did not complete either the pre- or the posttest and were thus excluded from statistical analysis. Therefore, the total number participating in this part of the study was 496.

The pre- and post-test results were compared at the end of each of 8 weeks (Figure 1).

As shown in Table 1, there was a significant difference in the overall mean average pre-test and post-test scores of 2.6 and 4.9 out of 7, respectively (p<0.0001).

Although not confirmed by statistical analysis, there appeared to be very little variation, week by week, in the scores for the pre- and post-tests, as well as for the comfort levels. (Figures 1, 2, 3) Comfort The comfort the students felt on recognizing cardiac sounds and respiratory sounds before and after the session were also compared during the 8 weeks, using a 5 level Likert Scale.

Of the 496 students who took the pre/post competence test, 72 students did not complete the pre/post cardiac sounds comfort levels appropriately, while 74 students did not complete the pre/post lung sounds comfort levels appropriately. These were excluded from the analysis based on our exclusion criteria, leaving n=424 for the cardiac sounds and n=422 for the lung sounds. The average weekly scores are illustrated in figures 2 and 3. Statistical analysis (Table 1) revealed that the difference in pre-and post- comfort levels were also significant (p<0.0001).

Overall, 80.20% felt more comfortable after the session. There were 16.97% who felt the same and 2.83% felt worse about their ability to recognize these sounds after the Sim Lab session.

Figure 3: Average weekly comfort level scores pre- and postSim Lab session – Lung sounds Table 1 Outcome measurements between student groups at pre- and post- testing in SGU Simulation Laboratory Clinical Skills sessions, spring 2011.

Characteristic

Figure 2: Average weekly comfort level scores pre and post Sim Lab session - Cardiac sounds

Correct sounds identified, overall score out of 7 (n=496) Pre-test Post-test Comfort in recognizing cardiac sounds (n=424) Pre-test Post-test Comfort in recognizing lung sounds (n=422) Pre-test Post-test

Mean (SD)

95% Confidence Intervals

Paired t-test p-value

(2.17 – 2.49)

< 0.0001

(1.08 – 1.24)

< 0.0001

(1.05 – 1.23)

< 0.0001

2.6 (1.6) 4.9 (1.6)

2.0 (0.8) 3.2 (0.8)

2.2 (0.8) 3.3 (0.9)

13

Caribbean Medical Journal INTRODUCTION OF A SIMULATION LABORATORY TO PRECLINICAL STUDENTS AT ST. GEORGE’S UNIVERSITY IN GRENADA

Discussion “Spanning the continuum of educational levels and bridging multiple health care professionals, medical simulations are increasingly finding a place among our tools for teaching and assessment [2].”

Simulation based medical education improved our basic science students’ ability to identify cardiac and respiratory sounds. Our study clearly showed that the students improved in both confidence and competence. The improvement in competence was based on the pre-test results in sound identification compared to post-test results. The increase in comfort level at the beginning of the session was compared to the comfort level at the end of the session using a Likert scale. Student comments included: “A good experience, made it much easier to differentiate the different heart and lung sounds”, “Great learning experience”, “Wow, best activity ever; best way to learn heart/breath sounds“ and “Very helpful; best rotation yet”.

There is a wealth of literature on simulation in anesthesiology and emergency medicine but less regarding use of simulation in basic science medical student education. Much of what is available is in the form of review articles. Undergraduate medical education is leaning more towards active learning, which has been shown to be more effective in adult learners.

Due to decreased lengths of hospital stay and less teaching time by faculty, there is less availability for groups of students to be involved with bedside learning. Simulation provides active learning, is interactive, teaches team work, and permits self assessment in a non judgmental environment. Additionally, the use of simulation during the undergraduate medical education years introduces the student to this type of educational activity which they will likely encounter again in the future.

The strengths of the study were that it was prospective, had very little variation in the sessions experienced by each of the students, had objective, measurable learning outcomes using the pre-and post-test results and also subjective learning outcomes of the individual student’s comfort level with his/her auscultation skills. The limited variation between sessions was also accomplished by: the use of the mannequins, detailed protocols, the presence of one of the four full time clinical skills faculty members and the Simulation Center operations managers at every session. There was little variation in the results of each of the 8 weeks suggesting that the students did not share the information between the groups.

The scheduling of the students was done with ease and the number of students in the Sim Lab at any time was very manageable. The possibility of incorporating a similar experience into the 4th term Communication and Physical Diagnosis course in the future and possibly having a mannequin station in our OSCE (Objective Structured Clinical Examination) are considerations. Student comments included: “Very good experience, should possibly be incorporated into CPD course, 4th term”, “We should have Sim Lab for CPD - really helpful”, “Can we do this more often?”, “Best rotation and most informative. There should be more Sim Labs per semester.”

Evaluation of whether the skills persist requires that future evaluation be done. Since students attend many different sites for their clinical rotations the continued assessment of their auscultatory skills is difficult. Incorporating the Sim Lab into 14

4th term would allow us to study the long term (from 4th term to 5th term) effectiveness of the lab.

McGaghie (2006) developed guidelines on high fidelity medical situations following review of 670 peer reviewed journal articles.

All of these guidelines were met in the use of the Sim Lab with the exception of an increasing level of difficulty during the session. As we consider introducing this experience earlier in the curriculum increasing levels of difficulty can be incorporated.

Some of the weaknesses of the study were: the Sim Lab was a new experience for all of those involved and therefore there may have been some variations in the facilitation of the stations.

Four areas were assessed by the students: site, preceptor, feedback and professionalism. Student comments included: “Preceptor instruction was good for both cardio patients, but not quite as good for asthma”, “Murmur station was lacking, tutors were not very helpful.” and “Respiratory preceptors were excellent, two cardiac preceptors were less useful, overall the best lab ever”. For the future, more formalized and individual feedback should be developed. The protocols used by the mannequins were also newly developed and require further review and alterations.

There were 18 teaching fellows involved with the sessions over the 8 week period. There was therefore variability in the teaching styles as well as in the experience of each of these fellows. All of these problems can be solved by limiting the number of fellows, providing more than 2 hours of training for those utilized in the Sim Lab and reviewing and revising patient protocols.

Other areas of the study which may require improvement in the future would be to ensure no sharing of information amongst the students during both the pre- and the post-test.

There were also a number of students who did not participate in either the pre-test or the post-test (although these non responders were not included in the results).

In summary, the incorporation of a Sim Lab with the objectives of learning normal and pathological cardiac and respiratory sounds showed a statistically significant improvement in second year medical students’ ability to correctly auscultate these sounds, and in the student’s comfort level in auscultation. It permitted the students to practice, and to question in a non threatening environment, and introduced them to simulation which will likely be part of their future education as residents and attending physicians. In addition it demonstrates that with planning of logistics, and involvement of faculty, large numbers of diverse students can actively participate in, and learn in a standardized clinical simulation utilizing high fidelity mannequins. It is possible that our data may be extrapolated to other medical schools as their enrollment increases, and demands increase. The Sim Lab was well received by both the students and the faculty and proved to be an excellent educational endeavor which will be incorporated into future curriculums.

Acknowledgements We would like to thanks the following persons for their contributions: Mr. John Speake, Technical Director of the Simulation Laboratory, for expert technical assistance.

Caribbean Medical Journal INTRODUCTION OF A SIMULATION LABORATORY TO PRECLINICAL STUDENTS AT ST. GEORGE’S UNIVERSITY IN GRENADA

Dr. Ianna Campbell, Senior Teaching Fellow and Dr. Wendell Wilson, Professor , and Course Director , Introduction to Clinical Medicine course , for organizing and assisting in the facilitation of the sessions.

Competing Interests: None declared Correspondence to: Jennifer K Rooney, MD, Department of Clinical Skills jrooney@sgu.edu St. George’s University, True Blue Campus P.O. Box 7, Grenada, West Indies

REFERENCES [1] Okundo Y, Bryson E, DeMaria Jr S, Jacobson L, Quinones J, Shen B, Levine A. The Utility of Simulation in Medical Education: What is the Evidence?

Mount Sinai Journal Of Medicine 2009. 76:330-343 [2] Scalese RJ, Obeso VT, Issenberg SB. Simulation Technology for Skills Training and Competency Assessment in Medical Education. J Gen Intern Med 23 (Suppl 1) 2007: 46-49.

[3] McGaghie WC, Issenberg SB, Petrusa ER, Scalese RJ. Effect of Practice on Standardised Learning Outcomes in Simulation-Based Medical Education.

Medical Education 2006: 40: 792-797.

[4] Ziv A, Wolpe PR, Small SD, Glick S. Simulation-Based Medical Education: An Ethical Imperative. Academic Medicine 2003: 78: 783-788 [5] Voelker R. Medical Simulation Gets Real. JAMA 2009: 302: 2190-2192.

[6] Fitch MT. Using High-Fidelity Emergency Simulation With Large Groups of Preclinical Medical Students in a Basic Science Course. Medical Teacher 2007: 29: 261-263.

15

Caribbean Medical Journal

Case Report Exposed Fracture of the Medial Malleolus: the Role of the Reconstructive Ladder K. Williams MBBS, R. Lalla, FRCS & S.P. Narinesingh, MRCS, PgDipAes(Distinction) Department of Plastic Surgery, Eric Williams Medical Sciences Complex, Trinidad ABSTRACT This is the first reported case of an adipofascial posterior tibial artery perforator flap in Trinidad and Tobago. The concept of the reconstructive ladder is discussed in order to illustrate the selection of this flap as the most appropriate reconstructive option. The case report describes the use of an adipofascial posterior tibial artery perforator flap to reconstruct a wound with an exposed fracture of the medial malleolus at its base.

INTRODUCTION The reconstructive ladder is a concept that is taught to plastic surgery trainees as one of the fundamentals of reconstruction.

For the purposes of this article it has been illustrated with six rungs.

as well as a retained bullet in the right foot. Of note, he smoked more than a half-pack of cigarettes per day for more than ten years. His initial care in the Emergency department by the orthopaedic team involved the correction and stabilisation of the displaced ankle, wound debridement and irrigation as well as empirical antibiotic treatment.

Six days post-injury the orthopaedic team did an open reduction and internal fixation of his malleolar fractures. The access to the medial malleolar fracture was via the existing laceration.

The wound was closed primarily. At the time of closure it was noted that the soft tissues around the medial malleolar laceration were of poor quality. This was due to the disruption of the microvasculature and soft tissue trauma at the time of injury.

During the time of fracture fixation, adequate exposure of the fracture fragments necessitated further mobilisation of the soft tissue around the medial malleolus. This would also contribute to reduced circulation at the wound edges. The inflammatory response to the wound from the time of injury also made the tissues oedematous and friable.

The skin over the medial malleolus underwent necrosis and progressed to purulent infection. Under the care of the orthopaedic team, the wound was debrided. The resulting wound had exposed fractured medial malleolus at the base.

Figure 1: The Reconstructive Ladder The bottom rung on the ladder is represented by healing by secondary intention and free flaps correspond to the top rung.

The degree of complexity of the reconstructive option increases from the bottom to the top rung.

The reconstructive ladder can be used to aid the selection of the most appropriate reconstructive option for a given defect. The original description suggested that one starts at the bottom rung of the ladder and selects the simplest option to achieve wound closure. So for example, if a wound will not close by secondary intention then one would ascend to the next rung of the ladder, that is, primary closure, and so on. This is illustrated using the case described below.

CASE REPORT This case involves a 29 year-old male who was injured whilst allegedly attempting to escape from men who were shooting at him. He jumped from an approximately six-foot high fence and sustained a right bimalleolar ankle fracture with talar shift .

There was a laceration over the medial malleolus. This wound, based on its appearance and location, was likely due to the soft tissue disruption around the open ankle fracture.

His other injuries included a soft tissue injury to the right thigh from a gunshot wound and a fracture of the right third metatarsal

16

Figure 2: The wound overlying a fracture of the medial malleolus, post-debridement

Figure 3: The medial malleolus is devoid of periosteum

Caribbean Medical Journal EXPOSED FRACTURE OF THE MEDIAL MALLEOLUS: THE ROLE OF THE RECONSTRUCTIVE LADDER

The kirschner pin and cancellous screw that had been used to stabilize the fracture were not exposed. This wound was treated with a negative pressure wound dressing as a temporising measure whilst the infection was treated with intravenous antibiotics.

Three weeks post-injury there was no further pus draining from the medial malleolar wound and healthy granulation was noted at the periphery.

Figure 7: The flap covered with split skin graft and the donor site closed primarily There was no partial or complete flap failure however there was approximately 85% graft take. As a result the flap required dressings for two weeks whilst the wound reepithelialised. The donor site healed without complication apart from a stitch abscess. The flap can be revised in the future to reduce its bulk, however the patient is not keen to have any further surgery.

Figure 4: Healthy granulation seen at wound edges following VAC therapy A posterior tibial artery perforator flap was done at this time.

The flap was raised as an adipofascial flap, that is, the subcutaneous tissue and deep fascia alone were raised.

Figure 8: Six weeks postoperatively Discussion THE RECONSTRUCTIVE LADDER Figure 5: Flap dissection completed with the flap lying in situ at donor site Skin was not included in the flap. The dimensions were 18cm x 5cm. Dissection deep to the flap was stopped at 8cm above the medial malleolus. The flap was turned over to cover the bone defect and the entire wound, including the flap, was then covered with a split skin graft taken from the left thigh. The flap donor site was closed primarily.

Secondary intention Healing by secondary intention was a poor option in this case.

The aim here was to attain definitive cover of the medial malleolar fracture in a short time in order to minimise the risk of bacterial contamination and further infection. Also healing by secondary intention was unlikely to succeed in this case given the surface area of exposed bone. A contributing factor to slow healing was that the patient is a smoker. Also, the tissue surrounding the wound had reduced vascularity due to trauma â&#x20AC;&#x201C; both at the time of injury and during fracture fixation.

Primary closure This was attempted following the fixation of the medial malleolar fracture but did not succeed. Primary closure is always the first option if it is possible without tension. It is the simplest method of attaining definitive wound cover while avoiding any concomitant donor site morbidity.

Figure 6: The flap turned over to cover medial malleolus

Skin graft A skin graft depends entirely on the recipient wound bed for vascularisation since it is separated from its original vascular

17

Caribbean Medical Journal EXPOSED FRACTURE OF THE MEDIAL MALLEOLUS: THE ROLE OF THE RECONSTRUCTIVE LADDER

supply. Bone denuded of periosteum does not provide adequate vascularisation of a skin graft with a few exceptions. For example for coverage of exposed denuded skull, the outer table can be burred to permit vascularisation of a skin graft via the diploe.

Another situation where bare bone can support a skin graft is when the defect is very small (<1cm2). In this circumstance the skin graft can maintain viability via its contact with the soft tissues at the wound edges. However in this medial malleolar defect a skin graft would not have survived.

Local flap A flap consists of tissue that is mobilized on the basis of its vascular anatomy. Flaps are composed of skin, fascia, adipose, muscle, bone and combinations of these. A local flap utilises tissue that is directly adjacent to the wound to obtain wound closure. A local flap was not a viable option in this case because the zone of injury included the tissue adjacent to the wound.

There was soft tissue trauma of the ankle at the time of injury.

This disrupted the vascular supply of the tissue adjacent to the wound. This was further compromised during the fixation of the medial malleolar fracture since it was necessary to dissect the skin and subcutaneous tissue around the medial malleolus in order to attain adequate fracture reduction and fixation. In addition the considerable post-trauma oedema would have limited the mobility of any local flap raised.

Distant flap Regional Pedicled Flap Distant flaps are not adjacent to the wound requiring reconstruction. This category can be further subdivided into regional and distant pedicled flaps and free flaps. For the reconstruction of complex wounds of the foot and distal third of the leg, regional pedicled flaps have declined in popularity in specialist institutions with microsurgical services. However they constitute the mainstay for the reconstruction of these complex wounds in other plastic surgery units worldwide. There are several regional options in this case, some of which will be discussed in order to elaborate on the choice of flap in this case.

Regional pedicled options included the distally based sural flap [1] and the saphenous neurocutaneous flap. [2, 3] However these flaps both depend on a blood supply via perforators and anastomoses in the region of the ankle. Due to the soft tissue trauma in this area, the vascularity of these flaps may have been compromised so they were not selected as a first choice option.

Another nearby option was the dorsalis pedis flap. [4, 5] This flap is based on tissue from the dorsum of the foot and is supplied by the dorsalis pedis artery. However the patient sustained a gunshot wound through the dorsum of the foot which exited in the sole of the foot. This disrupted some of the vessels perfusing the tissue that would have been raised with this flap. In addition, the use of this flap requires sacrifice of one of the primary vessels supplying the foot. This therefore would not have been an ideal option.

The posterior tibial artery perforator flap was a regional flap option which provided definitive and reliable cover in a single stage. The blood supply for this flap arises from posterior tibial artery perforators. This lies proximal to the zone of injury and

18

therefore was deemed the safest option for reconstruction of the medial malleolar defect.

The most reliable PTA perforators are found at 6 to 8 cm and 10 to 12 cm from the tip of the medial malleolus. [6] A PTA perforator flap can be reliably harvested within 10 cm of the popliteal skin crease. If a perforator is of sufficient calibre, the flap can be raised on a single perforator. In this case there was considerable oedema and products of blood degradation which prevented safe dissection of a PTA flap based on a single perforator. Therefore the flap was based on more than one PTA perforator.

Distant pedicled flap Pedicled flaps can be designed near to the defect, as in this case, or from an anatomically “distant” site such as the upper limb. Pedicled flaps from a distant site are only used when there are no other suitable options available since they can significantly limit the mobility of the patient. For example when a pedicled flap is raised from the groin to reconstruct an ipsilateral forearm defect, the patient’s mobility at shoulder, elbow, wrist and hips are reduced for at least 2 to 3 weeks. Pedicled flaps from distant sites are largely of historical interest. [7] However even in modern times this option may be deemed necessary. [8] Free flap A free flap is raised on a known blood supply which is completely detached from its donor site. This necessitates microvascular anastomoses to an artery and vein(s) at the recipient site for perfusion of the flap. The success rate of free flaps in tertiary centres with microsurgery services can approach 98%. [9] However, this success rate depends on multiple factors including specialised instruments and intensive nursing postoperatively in a high dependency unit. The description of the reconstructive ladder was a significant milestone that has since given reconstructive surgeons a structured approach to the treatment of all wounds. However this concept has its limitations. For example the original description does not take into account recent innovations in reconstruction such as the VAC dressing and dermal matrices. [10] Those who disagree with the concept of climbing a ladder of reconstruction argue that at times more complex methods of reconstruction may be preferred even when simpler methods can achieve wound closure. This has resulted in the concept of the “reconstructive triangle” [11] and the “reconstructive elevator”. [12] The “triangle” consists of tissue expansion, local flaps and microsurgery. The “elevator” acknowledges the concept of increasing levels of complexity whilst suggesting a greater freedom to ascend to the appropriate level.

However we believe that the concept of the reconstructive ladder still has an important role to play in the planning of a reconstruction. Rather than using the ladder to achieve “wound closure” it should be used to decide on the simplest option to achieve “definitive wound closure with the best functional outcome”. Instead of redefining the ladder should we instead not be redefining the reconstructive goals? The case report demonstrates that the reconstructive ladder is still standing despite attempts by many to trade it in for a newer model.

Caribbean Medical Journal EXPOSED FRACTURE OF THE MEDIAL MALLEOLUS: THE ROLE OF THE RECONSTRUCTIVE LADDER

Acknowledgements We wish to acknowledge Dr Curtis Young Pong, Orthopaedic consultant, and his team who initiated treatment of this patient and managed his Orthopaedic injuries.

Competing interests None declared Correspondence to: Kibileri Williams, Department of Surgery Eric Williams Medical Sciences Complex, Trinidad Email: kibileri@aol.com REFERENCES 1 Hollier L, Sharma S, Babigumira E, Klebuc M. Versatility of the sural fasciocutaneous flap in the coverage of lower extremity wounds. Plast Reconstr Surg 2002; 110: 1673-9.

2 Cavadas PC. Reversed saphenous neurocutaneous island flap: clinical experience and evolution to the posterior tibial perforator-saphenous subcutaneous flap. Plast Reconstr Surg 2003; 111: 837-9.

3 Cavadas PC. Reversed saphenous neurocutaneous island flap: clinical experience. Plast Reconstr Surg 1997; 99: 1940-6.

McCraw JB, Furlow LT Jr. The dorsalis pedis arterialized flap. A clinical study. Plast Reconstr Surg 1975; 55: 177-85.

5 Attinger CE, Evans KK, Bulan E, Blume P, Cooper P. Angiosomes of the foot and ankle and clinical implications for limb salvage: reconstruction, incisions, and revascularization. Plast Reconstr Surg 2006; 117: 261S-293S. 6 Schaverien MV, Hamilton SA, Fairburn N, Rao P, Quaba AA. Lower limb reconstruction using the islanded posterior tibial artery perforator flap. Plast Reconstr Surg 2010; 125: 1735-43.

7 Zimbler MS. Gaspare Tagliacozzi (1545-1599): renaissance surgeon. Arch Facial Plast Surg 2001; 3: 283-4.

8 Narinesingh SP, Wong J, McGrouther DA, Babar AZ. Descending the reconstructive ladder with tube pedicles. J Plast Reconstr Aesthet Surg 2010; 63:e217-9.

9 Armstrong MB, Masri N, Venugopal R. Reconstructive microsurgery: reviewing the past, anticipating the future. Clin Plast Surg 2001; 28:67186.

10 Janis JE, Kwon RK, Attinger CE. The new reconstructive ladder: modifications to the traditional model. Plast Reconstr Surg 2011; 127: 205S-212S. 11 Mathes SJ, Nahai F. Reconstructive Surgery: Principles, Anatomy and Technique. London: Churchill Livingstone. 1997; 4, 10.

12 Gottlieb LJ, Krieger LM. From the reconstructive ladder to the reconstructive elevator. Plast Reconstr Surg 1994; 93:1503-4.

4

19

Caribbean Medical Journal

Case Report Urethrocutaneous fistula post circumcision B. Rampersad FRCS & M. Fortuné MBBS Department of Paediatric Surgery, Eric Williams Medical Sciences Complex, Mt. Hope, Champs Fleurs, Trinidad and Tobago.

Abstract Urethrocutaneous fistulae post circumcision is a rare complication of medical circumcisions. This case report details a 2 year old male with a urethrocutaneous fistula after circumcision.

Keywords Urethrocutaneous fistula, circumcision complications Introduction Circumcision is one of the most popular elective surgical procedures for young males worldwide. This report highlights a case of urethrocutaneous fistula, one of the rare complications of circumcision. It also gives recommendations to decrease the likelihood of this complication occurring.

Case Presentation We present a case of a male patient who had a circumcision at 3 months of age at the parents request. It was performed by a General Practitioner under local anesthetic in his private office.

Initially, no complications were readily noticed by the parents.

About 6 months after the circumcision, his mother noticed urine leaking from the undersurface of the penis and a double stream.

His mother decided to adopt a watch and wait approach, but after 8 months when there was no change she went back to the General Practitioner. He examined the patient and then referred him to the Department of Paediatric Urology at the Eric Williams Medical Sciences Complex 1 year 2 months after circumcision.

At initial consultation when he was 1 year and 10 months old, he was noted to have a ventral urethrocutaneous fistula which was clearly evident on micturition (Figure 1).

Outcome On review in the Out Patient Clinic 2 weeks post op, no complications were reported. Micturition was witnessed and a single stream was seen with no obvious leak. On further review 8 months post procedure, there was no recurrence of the fistula and he had a normal stream from the meatus (Figure 3). (He was reviewed in clinic about 2 weeks after repair and had no problems at home. In clinic, on micturition no leak was observed and he was micturating in one stream through the normally situated urethral meatus. On his last review on April 19 2012, he was still micturating through the normally situated meatus with no ventral leak and had no complaints.)

Illustrations and figures

Figure 1. Pre operative urethrocutaneous fistula ventral aspect penis 5/8/2011

His penis also had a ‘two toned’ appearances due to the fact that the outer foreskin was deficient for some distance below the glans penis and the inner layer of the prepuce, which is hypopigmented, was now covering the distal penile shaft (Figure 3.).

Surgical Repair He had (a) repair of the urethrocutaneous fistula done when he was 2 years 4 months old, 11 months after referral to the Department of Paediatric Urology and 6 months after first consultation. Under General Anaesthesia the patient was initially catheterized using a 6 French Silicone Foley’s catheter. An elliptical incision was made circumscribing the fistula. The surrounding skin was then mobilized. The edges of the urethral defect were excised and then repaired with 6-0 PDS interrupted sutures transversely (Figure 2). A further dartos layer was developed and closed longitudinally with 6-0 PDS interrupted sutures over the fistula repair to reduce the chance of recurrence.

The skin was closed transversely with 6-0 PDS interrupted sutures.

20

Figure 2. The urethral defect was excised then repaired with 6-0 PDS interrupted sutures

Figure 3. Eight months post-op repair of urethral fistula showing ‘two-toned’ appearance

Caribbean Medical Journal

URETHROCUTANEOUS FISTULA POST CIRCUMCISION

and eventually will give rise to the “two-toned” appearance of the penis and may cause painful erections.

Figure 4. Stretching of foreskin and application of Plastibell Discussion Circumcisions remain a common surgical procedure. Due to its ubiquitousness, it is sometimes taken for granted the complications which may occur. These include, but are not limited to, urethral fistulae, total or partial glans amputation, urethral stricture of the meatus, penile pseudo elephantiasis, penile denudation, hemorrhage and septicaemia [1, 2, 3, 4]. Our case highlights one of these complications – urethrocutaneous fistula.

The urethra at the level of the coronal sulcus is most prone to injury due to its superficial location at this point. The method of “pulling” the foreskin over the glans before amputation or application of the Plastibell (often used in neonates) can tent the urethra and predispose to injury at the coronal sulcus (Figure 4. http://www.circumcisonquotes.com/ plastibelldrawings.html) This can be either direct trauma to the urethral wall or damage by excision, ischaemia or suture incorporation.

To avoid this complication, the foreskin must not be stretched excessively before excision or application of the Plastibell. The surgeon should preserve at least 5 mm of the inner layer of the foreskin distal to the coronal sulcus and sutures must not be placed too deep to incorporate the urethra. If an excessive amount of the outer layer of the foreskin is excised this causes migration of the inner layer of foreskin to the proximal shaft

Conclusion Circumcision remains a common surgical procedure in young males. Although urethrocutaneous fistula is a rare complication, all care must be taken to avoid this complication as it is not always easily repaired. Therefore there is a need for circumcision especially in young children to be performed by suitably trained personnel. In spite of this, complications do occur and although rare can include urethrocutaneous fistulae [2]. This case history highlights such a complication and the need for the procedure to be done by medical personnel specifically trained in the procedure and the attention that must be paid to the ventral aspect of the penis near the urethra while performing a circumcision.

Acknowledgements Parents of J.C.M. (case) Competing interests None declared Corresponding Author Ms. Barbara Rampersad – Paediatric Surgeon / Urologist, Eric Williams Medical Sciences Complex, Mt. Hope, Champs Fleurs, Trinidad and Tobago.

Tel. No. 868-645-4673 REFERENCES 1. Sylla C, Diao B, Diallo AB, Fall PA, Sankale AA, Ba M. Complications of circumcision. Report of 63 cases. Prog Urol. 2003 Apr; 13(2):266-2.

2. Sancaktutar AA, Pembegül N, Bozkurt Y, Kolcu B, Tepeler A. Multiple circumferential urethrocutaneous fistulae as a rare complication of circumcision and review of literature. Urology. 2011 Mar;77(3):728-9. Epub 2010 Aug 30 3. Dieth AG, Moh-Ello N, Fiogbe M, Yao KJ, Tembely S, Bandre E, Gouli JC, Odehouri T, Meledje OB, Ouattara O, Dick KR, da Silva-Anoma S. Accidents of circumcision in children in Abidjan, Côte d'Ivoire. Bull Soc Pathol Exot.

2008 Oct;101(4):314-5.

4. Ceylan K, Burhan K, Yilmaz Y, Can S, Ku? A, Mustafa G. Severe complications of circumcision: an analysis of 48 cases. J Pediatr Urol. 2007 Feb;3(1):325. Epub 2006 Jun 9

21

Caribbean Medical Journal

Cardiology The Cardiac Catheterization Lab: Implementing Best Practice in Trinidad and Tobago C. Thomas1 FRCP, L. Boodhoo2 MRCP, M. Chacko3 FACC, R. Rampersad4 CC(V), E. Afoon-Williams1 BSc, P. Ramoutar2 MRCP, S. Gieowarsingh1 MRCP, D. Alexander1 FRCP(C), S. Ramphall1MRCP(I), R. Rahaman1FRCP, P. Lall5 FRCS(Ed), B. Bird1 MRCP &T. Cummings1 FRCP. 1

- North Central Regional Health Authority (NCRHA), - South West Regional Health Authority (SWRHA), 3 - Trinidad and Tobago Health Sciences Initiative (TTHSI), 2 4 5

- Caribbean Heart Care Medcorp, (CHCm), - The University of the West Indies (UWI)

Executive Summary On 13 May 2012, the Quarterly Cardiology Conference program was organized by the Trinidad and Tobago Medical Association and The University of the West Indies, St. Augustine. The program provided a forum for discussion of issues related to the implementation of best practices in the management of patients requiring cardiac catheterization laboratory (Cath Lab) procedures. The participants who were stakeholders in the management of patients referred for catheter-based procedures reviewed best practice guidelines for patients, identified local barriers to the implementation of these best practices and made recommendations for the implementation of these best practice guidelines.

Barriers to best practice were related to sub-optimal management of facilities, equipment and human resources. Trinidad and Tobago’s Cath Labs perform only a fraction of the estimated number of procedures required annually per million population.

The private sector provides Cath Lab services with relatively short waiting times for some of the patients in need. The Ministry of Health Cardiac Program for the “Indigent” also provides access for a fraction of the public patients in need of Cath Lab services. There is however a need to reorganize the referral and approval process to ensure timely access to the cardiac services for a broader spectrum of public patients.

The American College of Cardiology (ACC) and the American Heart Association (AHA) have published guidelines and indications for performing Cath Lab procedures. Modified ACC/AHA criteria tailored to the region’s population and the expertise of the local practitioners have been formulated to determine which patients should be eligible for diagnostic and interventional procedures in Trinidad and Tobago. Pre-approval for class I (generally accepted) indications, request for approval for class II (debatable) indications and denial of approval for class III (contra-) indications is recommended. Eligible patients should be triaged as emergent, urgent or elective based on clinical criteria.

A service agreement between the authorities from the Cath Labs, RHAs and MoH, facilitated through Information and Communication Technology (ICT) is recommended to facilitate the fast tracking of the referral process for Public Sector Cath Lab procedures. Concurrent improvements to the facility, human resources, equipment and supply chain management for the Cath Lab and related departments (eg Coronary Care Unit) should accompany the reformed referral process.

22

A Cardiology Department with subspecialty clinics at the tertiary center is needed to facilitate rapid diagnosis, triage and management of patients who need these Cath Lab Procedures.

Improved management of the human resources staffing these dedicated cardiology services 24/7, appropriate non-invasive and invasive equipment, relevant ICT software and hardware, durable maintenance contracts and efficient supply chain for the inventory are of critical importance to achieve a Centre of Excellence utilizing “Best Practice” Guidelines in the public sector Cath Lab services. Functioning in this manner the Public Sector Cath Lab program could provide the necessary service that would play a major role in satisfying our national demand and contribute to reducing morbidity and mortality attributable to cardiovascular disease.

Introduction The incidence, prevalence, morbidity and mortality due to cardiovascular diseases are very high in the developing Caribbean Region. The cardiac catheterization laboratory (Cath Lab) provides services essential for diagnosing and treating a broad spectrum of cardiovascular diseases. Cath Lab Services in Trinidad and Tobago and the Caribbean Region are limited in depth, breadth and accessibility. Contributing to the limited services are comparatively low public health care expenditure (as a percentage of GDP) and insufficient trained medical professionals. This is compounded by the absence of national and regional cardiac strategies that would help prioritize how the health care budget should be spent for patients with cardiovascular diseases. In Trinidad and Tobago, patients can access Cath Lab Services via the private or the public sector Cath Labs. Access to the public sector Cath Lab was initially provided for “indigent” patients and this program has since expanded to provide access for more patients in the public sector. Access to this program is poorly understood by referring physicians and the referral process is considered inefficient.

The procedural volume for the public sector program is considered to be only a fraction of the nation’s demand. Access to these specialized Cath Lab services would benefit from careful evaluation with a view to reform.

The American College of Cardiology (ACC) and the American Heart Association (AHA) have published guidelines and indications for performing Cath Lab procedures including Percutaneous insertions PCI [1, 2], pacemakers [3] and peripheral intervention [4]). Conforming to best practice guidelines avoids unnecessary procedures, improves access for those patients

Caribbean Medical Journal THE CARDIAC CATHETERIZATION LAB: IMPLEMENTING BEST PRACTICE IN TRINIDAD AND TOBAGO

most in need and most importantly is associated with improved procedural outcome (5). The Trinidad and Tobago Medical Association and the Faculty of Medical Sciences, The University of the West Indies organized a conference on Best Practices in Cath Lab Services in Trinidad and Tobago. The half day program provided a forum for discussion of issues related to the implementation of best practices in the management of patients referred for Cath Lab procedures. The target audience was doctors and administrators who are key stakeholders in the management of patients referred for catheter-based procedures.

The goal was for participants to review best practice guidelines for patients referred for catheter-based procedures, to identify local barriers to the implementation of these best practices and to make recommendations for the implementation of appropriate best practice guidelines for Trinidad and Tobago and the Caribbean Region. The conference was divided into three sessions. Indications for catheter based procedures were presented in the first session. In the second session the public sector referral process was evaluated as viewed from four key stake holders, the Ministry of Health, the private Cath Labs, the public Cath Lab and the referring Public Hospitals. The barriers to the implementation of best practice guidelines and the changes required to remove the barriers were discussed in the third session using three Cath Lab subspecialty workshops. An electronic audience response to 10 multiple choice questions was then used to determine whether there was consensus in the main problems identified and solutions recommended.

SESSION I: INDICATIONS FOR CATHETER BASED PROCEDURES Indications for Cardiac Catheterization and Percutaneous Coronary Intervention.

Dr. Clifford Thomas Left and Right Cardiac Catheterization with Coronary Angiography provides information that is useful for diagnosing and selecting optimal therapy for patients with coronary, valvular, congenital and other structural heart disorders. It is estimated that 3000 cardiac catheterization with coronary angiogram procedures are required annually per million population to meet patient demand for this service in Trinidad and Tobago.

Approximately 25% of patients undergoing coronary angiography are candidates for Percutaneous Coronary Intervention (PCI).

Referrals to the Public Sector Cath Lab Program should specify whether the patient has any generally accepted indications (Class I) or contraindications (Class III) for the procedures. Referrals for procedures should also be classified as emergent (to be performed within 2 hours), urgent (48 -72 hours) or elective (placed on a waiting list).

Acute occlusion of a large epicardial coronary artery causing ST elevation myocardial infarction (STEMI) is a Class I indication for either thrombolysis or emergent coronary angiography with primary PCI. Primary PCI for STEMI (performed within ninety minutes of arrival to hospital) as the default option is considered best practice in medical centers with an experienced Emergency Medical (Ambulance) Response, Emergency Department, Cath Lab and Coronary Care Unit Programs. Patients with unstable angina, nSTEMI or Class IIIV angina who are at a high risk of an adverse event based on

clinical or non-invasive laboratory findings are Class I indications for urgent or elective coronary angiography respectively.

Although heart failure and structural heart disease are best diagnosed by non-invasive tests, coronary angiography is sometimes indicated to determine whether coronary artery disease is the underlying cause or needs to be corrected. Severe co-morbidities and unnecessary procedures are the main contraindications to coronary angiography. Patients with Class I indications for coronary angiography who have a severe stenosis supplying a large viable myocardial territory have a Class I indication for revascularization with PCI. We recommend that the Public Sector Cath Lab Program utilizes a modified ACC/AHA list of indications as a guide for approving procedures and develops protocols for handling emergent, urgent and elective referrals for cardiac catheterization, coronary angiography and PCI. Indications for Cardiac Implantable Electronic Devices, Electrophysiology Studies and Ablation.

Dr. Lana Boodhoo Cardiac implantable electronic devices (CIEDs) include permanent pacemakers, implantable cardioverter defibrillators (ICDs) and cardiac resynchronisation devices (CRT) with or without ICD. Indications for permanent pacemakers include sick sinus syndrome, symptomatic sinus bradycardia, atrial fibrillation with slow ventricular rates, third degree AV block, and chronotropic incompetence (inability to increase the heart rate to match a level of exercise). ICDs treat ventricular arrhythmias and are recommended for primary and secondary prevention of sudden cardiac death in selected patients with ischemic and non-ischemic cardiomyopathy. CRT improves left ventricular function and is recommended in patients with heart failure, severe systolic dysfunction and prolonged QRS. Electrophysiology Studies (EPS) identify the presence and mechanism of arrhythmia. Catheter ablation destroys parts of the abnormal electrical pathway or circuit that is causing the arrhythmia. EP procedures are accepted as primary therapy for most patients with supraventricular tachycardia and for several forms of ventricular tachycardia.

The estimated numbers per million population of CIEDs required annually in Trinidad and Tobago are as follows: New pacemakers: 500; pacemaker replacements: 125; new ICDs: 100; CRT: 50.

The estimated number of EP procedures required annually is 250. Modified Class I, II and III indications for procedures are recommended based upon local demographics and resources.

Eligible patients should be triaged as urgent or elective based on clinical criteria. Heart Rhythm clinics at tertiary centers can facilitate rapid diagnosis, triage and management of patients who have indications for these Cath Lab Procedures.

Indications for Peripheral Angiography and Non-Coronary Intervention.

Dr. Matthews Chacko Cardiovascular disease is the leading cause of death within the Caribbean. Atherosclerosis is a systemic disease and is identified

23

Caribbean Medical Journal THE CARDIAC CATHETERIZATION LAB: IMPLEMENTING BEST PRACTICE IN TRINIDAD AND TOBAGO

as the predominant underlying pathology in coronary, cerebrovascular and peripheral artery disease leading to acute myocardial infarction, stroke, Transient Ischemic Attack (TIA) and limb loss respectively. Structural heart disease is an important component of cardiovascular disease and leads to morbidity and mortality in patients of all ages. Catheter-based therapies for non-coronary atherosclerotic vascular disease as well as structural heart disease have improved substantially over the past decade and offer effective and less invasive treatment options for many patients.

As with cardiac catheterization and PCI, the Public Sector Cath lab will have a pivotal role in providing some of these cutting edge catheter-based treatments and procedures to the public sector patients in Trinidad and Tobago. Modified ACC/AHA criteria germane to the Trinidad and Tobago population and the expertise of the local practitioners should be developed to determine which patients are eligible for vascular and structural heart disease interventions along with protocols triaging those procedures that are considered emergent, urgent or elective in nature.

SESSION II: THE PUBLIC SECTOR REFERRAL P R O C E S S F O R C AT H L A B P R O C E D U R E S The Role of the Social Worker in the Ministry of Health Cardiac Program for the Indigent.

Elizabeth Afoon-Williams A large proportion of Trinidad and Tobago patients in need of cardiac services are not covered by medical insurance and cannot access private health care. The Medical Social Worker in the Ministry of Health (MoH) Cardiac Program for the Indigent works with patients to provide supportive, diagnostic, medical and surgical intervention. Social work intervention with clients is an on-going process throughout their treatment and recovery.

Social work intervention also recognizes the many systems with which the patients are interacting and seeks to maximize the positive relationships within their social network and develop potentially positive links.

The MoH has been financing cardiac procedures for indigent public patients from all RHAs in Trinidad and Tobago. The procedures have been done at both the public and private institutions. Initially requests for cardiac procedures were addressed to the Office of the Chief Medical Officer through the Medical Chief of Staff of the RHA Hospitals and the RHA Hospital Medical Social Worker. The requests were mainly for cardiac caths, coronary angioplasties, pacemakers, open heart surgery, peripheral angiograms and angioplasties. This process is currently under review and proof that the patient is indigent is not always required.

The role of the Social Worker is dynamic and meets the changing needs of the clients. Social Workers often engage in their tasks with insufficient resources at their disposal. Not all procedures that were requested were approved and not all approved procedures were performed. The average waiting time for procedures needs to be shortened.

In spite of these limitations, the Ministry of Health Cardiac Program for the Indigent has positively impacted many 24

individuals and by extension their families, through the gift of life and better health. There is however a need to reorganize the referral and approval process to ensure timely access to the cardiac services for a broader spectrum of public patients.

A Private Cardiac Catheterization Program in Trinidad and Tobago: The burden of care, supply and demand.

Dr. Risshi Rampersad Cardiovascular disease is the leading cause of death in Trinidad and Tobago (24.1% reported mortality in 2004). There is no statistical data on the incidence or prevalence of coronary artery disease (CAD) but some indication can be extrapolated from the volume of cardiac procedures performed in recent years.

Caribbean Heart Care Medcorp (CHCm) has performed an average of 345 cardiac surgery procedures and over 1000 cardiac catheterizations annually over the last 5 years. This is probably just the tip of an iceberg with a burden of care remaining due to inaccessibility of emergent catheterization and primary angioplasty and timely elective catheterization for patients in the public sector.

The CHCm cardiac catheterization program has provided services for the Ministry of Health (MoH) for over 7 years and is fully integrated with the CHC cardiac surgery service (which since its establishment in 1993 has performed over 3000 cardiac surgery cases with mortality and morbidity equal to the best international centers). The CHCm program is run by very experienced interventionalists from institutions (Bristol Heart Institute, UK and the Association Cardiovascular, Ascardio, Venezuela) doing high volume procedures. CHCm also works with high volume operators from other countries such Brazil, USA, and Canada. The program strictly follows the ACC, AHA and ESC Guidelines. In the last 5 years we have established a 24 hour emergency angioplasty service with a team that has door to balloon times, morbidity and mortality results comparable with the best international standards. Unfortunately, the long waiting time for Ministry of Health approval for public patients hinders the development of such an ambitious and innovative program. CHCm also runs a private catheterization program for non-coronary intervention including cerebral, peripheral, aortic intervention and uterine tumour embolization.

The primary mission of CHCm program has been and continues to be the introduction of new procedures in Trinidad and Tobago, access to highly specialised training programs for nurses, technician and doctors and most importantly, accountability to patients and the MoH. CHCm is providing a first class elective and emergency cardiology, surgery and ICU care program with short waiting times at affordable costs for the population of Trinidad and Tobago and the rest of the Caribbean islands.

Improving the Public Sector Cath Lab Services.

Dr. Clifford Thomas The number of Cath Lab procedures performed annually in Trinidad and Tobago does not currently satisfy the national demand. Assuming the Ministry of Health (MoH) Public Sector Program will provide services to meet a significant proportion of this national demand and that citizens from all Regional Health Authorities (RHAs) would be able to access this service at the Public Sector Cath Lab program, then a Service Agreement between the Cath Lab, the RHAs and the MoH would be

Caribbean Medical Journal THE CARDIAC CATHETERIZATION LAB: IMPLEMENTING BEST PRACTICE IN TRINIDAD AND TOBAGO

desirable to formalize the Public Sector Cath Lab Program.

The service agreement should include details of how RHA institutions should refer patients for Cath Lab Procedures and details of how each RHA institution would follow up patients after undergoing the procedure.

The annual procedural volume and budget for Cath Lab procedures should be estimated for each RHA based on the relative adult populations of the RHAs. The budgeted amount should be secured and accessed by each RHA that provides basic cardiac management, referral and follow up for its patients needing this service. There would need to be a simple method for verifying national identity and address and subsequent RHA Categorization for patients being referred from different RHA institutions.

A Standardized Form should be utilized for requesting procedures at the Public Sector Cath Lab. The Standardized Form should facilitate automation of the complete loop from referral, approval, scheduling, reporting to follow up and auditing.

The service agreement approved procedural volume, budget, list of indications and protocols should be developed for Cardiac Catheterization, PCI, CABG, Device Implantation, EP procedures, Peripheral angiography and Non-Coronary Intervention. With such concrete support the Public Sector Cath Lab program could provide the necessary service that would play a major role in satisfying our national demand.

Improving Communication to Optimize Follow up Care.

Dr. Pravinde Ramoutar The South West Regional Health Authority (SWRHA) refers and follows up patients undergoing Cath Lab Procedures at public and private institutions. The SWRHA is responsible for a population of approximately 700,000 persons. This population has a high prevalence of coronary artery disease. For the first three months of 2012 the Cardiac Unit at San Fernando General Hospital (which sees only a fraction of SWRHA cardiac patients) referred 247 patients for angiograms and 37 patients for device implantation or EP procedures.

Inadequate communication between the SWRHA Referring Hospital and the Cath Labs performing the procedures compromises patient care. When the SWRHA refers a patient for an angiogram or intervention, the patient is placed on a waiting list without relevance to clinical urgency. Often patients referred for a right heart catheterization get a left heart catheterization with coronary angiography instead. When patients undergo angiography and the proceduralist recommends intervention, the patient is sent back to the referring physician at the SWRHA to seek an appointment and subsequently be referred back for the intervention procedure. This often leads to delays in patient care which are significant since Cath Lab Studies are sometimes considered valid for only six months.

There is chronic overcrowding of the SWRHA inpatient and outpatient services with cardiac patients. The San Fernando General Hospital manages large numbers of public patients with suspected and proven coronary artery disease and needs to process numerous referrals for those patients who have Class I indications for Cath Lab procedures. As a region seeking to improve care of its cardiac patients, the SWRHA requires better

access to diagnostic and interventional procedures at the Public Cath Labs. Considering the high demand for Cath Lab Services in South Trinidad, the establishment of an additional Cath Labs in South Trinidad should be actively pursued.

SESSION III: BARRIERS TO BEST PRACTICE GUIDELINES S. Gieowarsingh, D. Alexander, S. Ramphall, R. Rahaman, P. Lall, B. Bird, T. Cummings Moderated Workshop Case Presentations and Discussion The work shop was divided into three group-sessions (25 participants per group) based on three Cath Lab subspecialties.

The moderators repeated the workshop for each group. Six case presentations from the Public Cath Lab at EWMSC were discussed. The cases represented the type of procedures that are performed at the public hospital Cath Lab. Participants then identified barriers to best practice for public patients in need of these Cath Lab services. The barriers were related to inadequate or poorly managed facilities, equipment and human resources.

Cardiac Catheterization and Percutaneous Coronary Intervention: The inefficient referral process results in prolonged waiting times between referral and procedure completion.

Physicians at public and private hospitals and outpatient clinics require more information about terms and conditions for accessing specialized care in the public sector Cath Lab Program.

The referral process is confusing to referring physicians and is in need of reform. Some participants proposed that a standardized referral form would facilitate the process in a transparent and more efficient manner. There is also need for a system, based on clinical criteria for triaging patients who need emergent, urgent or elective procedures. This should be done by clinical staff based either at the Ministry of Health or the Destination Cath Lab. Referring physicians expressed a need to communicate verbally with the physicians assessing their patients and performing the procedures. It was felt that confirmation of receipt of request for a procedure should be sent to both patient and the referring physician after which there should be a specified waiting time for the procedure. Human resources need to be aligned with a vision for the development of the Cardiology Services. A tertiary referral center with a 24/7 Cath Lab, Coronary Care Unit, Emergency Department and Ambulances should be designated for handling complicated acute coronary syndrome patients. Participants felt that Referral Hospitals with Cath Labs should have an interventional cardiology clinic and that the Cardiology team at the tertiary care referral hospital should give up internal medicine services so as to better focus on delivering comprehensive cardiology services.

Cardiac Implantable Electronic Devices, Electrophysiology and Ablation: Temporary pacing services should be established at all major health institutions in the country as a matter of urgency. The Eric Williams Medical Sciences Complex is the only public sector hospital providing Cardiac Device Implantation services despite an overwhelming desire by all participants to have it at their institution. It was highlighted that there is no governmental funding for devices and for the past 27 years the only source of a regular supply of implantable devices was a charitable organization, Heartbeat International. Participants expressed their frustration in managing patients needing devices.

25

Caribbean Medical Journal THE CARDIAC CATHETERIZATION LAB: IMPLEMENTING BEST PRACTICE IN TRINIDAD AND TOBAGO

Lack of timely device implantation results in the unnecessary cost of keeping patients in hospitals for prolonged periods whilst awaiting implant. The expenses from just one long-stay patient could fund the purchase of several pacemakers. The group felt that the Regional Health Authorities and the Ministry of Health should embark on a comprehensive program aimed at providing implantable devices for all patients who are citizens of Trinidad and Tobago. Community physicians managing patients with complex arrhythmias expressed a need for an efficient referral system for a specialist consultation and appropriate treatment at cardiology clinics or sub-specialty arrhythmia clinics.

Peripheral Angiography and Non-Coronary Intervention: It was suggested that general practitioners at health centers should have clear guidelines and protocols for managing and referring patients with peripheral arterial disease, aneurysms and structural heart disease. Equipment for performing ultrasonography, doppler and ankle/brachial index should be available at the outpatient clinic. More trained specialists attached to referral clinics, an efficient referral process (with improved communication between the referring physician and the proceduralist) and approved funding for the program need to be secured.

Question and Audience Response An electronic audience response to 10 multiple choice questions was then used to determine whether there was consensus in the main problems identified and solutions recommended. In general there was a strong consensus opinion for almost every question presented. The definite need for improved access to interventional and electrophysiology services was made clear by this large gathering of Trinidad and Tobago’s physicians. The majority of responders felt that patients in Trinidad and Tobago do not have timely access to a Cath Lab, that the development of clear guidelines, indications and protocols for Cath Lab referrals would be helpful and that the Ministry of Health needs to address the process by which public sector patients access such care.

There was also a general consensus that there were not enough specialty cardiology clinics (intervention, peripheral disease and electrophysiology) in the public sector to cater to the patient population in need. Most responders felt that interventional cardiology clinics should be made available in all regions rather than have them centralised at the Eric Williams Medical Sciences Complex. Almost half of the responders felt comfortable diagnosing arrhythmias and using guidelines to determine when to refer for subspecialty consultation, EP studies, pacemakers, defibrillator and resynchronization therapies. Most felt that vascular interventional services should be part of the current public sector cardiac program. There was a general feeling that a combination of private and public sector labs, but primarily public sector, should address the Cath Lab needs of the population, although a quarter of voters thought the effort should be mostly addressed by private sector labs. While just over half of those present felt that the consensus opinions should be reported to the Ministry of Health so that appropriate changes could be made, almost as many were fearful that little change in public sector health care policy would result and that the quality of service would remain inadequate.

CONCLUSION Private and public Cath Labs have provided and should continue to provide a broad and expanding spectrum of cardiovascular services for more patients. The system that provides access for 26

public patients is inefficient. Reform should be based on estimated demand for procedures, a calculated budget for Cath Lab services and a service agreement between the Cath Lab, the RHAs and the Ministry of Health. In addition protocols and clinical criteria for pre-approval and triaging of patients referred for catheterbased procedures are urgently needed to improve the efficiency and transparency of the referral process. Pre-approval for class I (generally accepted) indications, request for approval for class II (debatable) indications and denial of approval for class III (contra-) indications is recommended. Improvements to the facility, human resources, equipment, maintenance, supply chain and management of the public Cath Lab with alignment of human resources under one umbrella are recommended to achieve best practice guidelines and establish a Public Sector Cath Lab Centre of Excellence.

ACKNOWLEDGEMENTS 1. The Ministry of Health, Republic of Trinidad and Tobago 2. The Trinidad and Tobago Medical Association 3. The University of the West Indies, St Augustine, Faculty of Medical Sciences 4. Johns Hopkins University, Baltimore, MD, Department of Cardiology 5. Meeting Sponsors: Advanced Cardiovascular Institute (ACI), Caribbean Vending Services (CVS) Caribbean Heart Care Medcorp (CHCm), SurgiMed and Merck 6. Crowne Plaza Hotel, Port of Spain Trinidad and Tobago Competing Interests: Non delcared Address for correspondence: Dr. Clifford N. Thomas. MBBS, MD, FRCP Department of Medicine, EWMSC, Champs Fleurs, Trinidad and Tobago Tel: 868 645 2645 ext 2924, Fax: 868 662 7020, email: cliff7thomas@yahoo.com REFERENCES (1) Smith S, Hirshfeld J, Jacobs A, Kern M, MD, King S, Morrison D, O’Neill W, Schaff H, Whitlow P, Williams D. ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2006;113;e166-e286.

(2) Smith SC, Jr, Dove JT, Jacobs AK, Kennedy JW, Kereiakes D, Kern MJ, Kuntz RE, Popma JJ, Schaff HV, Williams DO. ACC/AHA guidelines for percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.

J Am Coll Cardiol 2001;37:2239i–lxvi.

(3) Epstein AE, DiMarco JP, Ellenbogen KA, Estes NA 3rd, Freedman RA, Gettes LS, Gillinov AM, Gregoratos G, Hammill SC, Hayes DL, Hlatky MA, Newby LK, Page RL, Schoenfeld MH, Silka MJ, Stevenson LW, Sweeney MO, Smith SC Jr, Jacobs AK, Adams CD, Anderson JL, Buller CE, Creager MA, Ettinger SM, Faxon DP, Halperin JL, Hiratzka LF, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura RA, Ornato JP, Page RL, Riegel B, Tarkington LG, Yancy CW. ACC/AHA/HRS 2008 guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: Executive Summary.Heart Rhythm. 2008 Jun;5(6):934-55. (Epub 2008 May 19).

(4) Hirsch A, Haskal Z, Hertzer N, Bakal C, Creager M, Halperin J, Hiratzka L, Murphy W, Olin J, Puschett J, Rosenfield K, Sacks D, Stanley J, Taylor L, White C, White J, White R. ACC/AHA 2005 Practice Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic). Circulation 2006;113;e463-e465.

(5) H. Vernon Anderson, MD; Richard E. Shaw, PhD; Ralph G. Brindis, MD; Lloyd W. Klein, MD; Charles R. McKay, MD; Michael A. Kutcher, MD; Ronald J. Krone, MD; Michael J. Wolk, MD; Sidney C. Smith Jr, MD; William S. Weintraub, MD. Relationship Between Procedure Indications and Outcomes of Percutaneous Coronary Interventions by American College of Cardiology/American Heart Association Task Force Guidelines.

Circulation. 2005; 112: 2786-2791.

Caribbean Medical Journal

Psychiatry Substance Abuse as A Public Health Problem Professor Gerard Hutchinson DM Psychiatry Unit, Department of Clinical Medical Sciences Faculty of Medical Sciences, Mount Hope

ABSTRACT This paper seeks to frame substance use and abuse in the context of public health in Trinidad and Tobago. This would ensure that the negative health and social consequences of substance use are reduced. This understanding would impact on the intersection of substance use and a range of pressing health issues including HIV/AIDS and social issues such as delinquency and crime.

These intersections apply to all of the commonly used drugs though most of the literature reviewed focuses on alcohol.

Introduction Substance abuse is being increasingly recognized as a major public health problem. Alcohol is directly responsible for at least 2.5 million deaths annually worldwide and indirectly causes significant disability because of its effects on physical and mental health and disruptive behaviour [1]. These in turn create enormous costs for health services as well as a major emotional, economic and social burden. In the United States, substance abuse is estimated to cost the country 484 billion US$ per year compared to diabetes 131.7 million and cancer 171.6 million US$. These costs include those associated with health care, lost earnings and the outcome of crime and accidents [2]. Nicotine use is also associated with a range of negative health outcomes including various cancers, gastrointestinal and vascular pathology.

It is also associated with second hand effects which compromise the health of those who have lived in close proximity to heavy smokers. [3] The legally available drugs alcohol and nicotine therefore cause significantly more negative health related outcomes such as death and disability because of their widespread and unregulated use [4]. The illicit drugs are also sources of negative public health consequences partly due to the direct impact of these drugs on the body but also because of the psycho-social issues related to engaging in illicit activity. These include crime, violence and delinquency in adolescence, educational underachievement and loss of productivity through time spent seeking or using these drugs instead of working or attending to other social responsibilities [5].

The Public Health Perspective A public health perspective first of all takes a population approach rather than an individual one. It focuses on reducing harm and minimizing risk in the potentially affected populations. Public health therefore consists of improving the health of communities through the reduction of disease and the social, environmental and population based factors that would facilitate disease. The Institute of Medicine in the United States in 1988 published a report, ‘The Future of Public Health’, and defined public health as the ‘organized community effort to seek the public interest to improve health and prevent disease through the application of available technical and scientific knowledge’ [6]. Substance use is extremely relevant to this definition as it can affect a wide range of individuals including those not directly associated with the use of a substance as in the case of accidents, violent injury,

criminal activity and second hand smoke. It is worth noting here the difference between substance ‘use’; the use of substances on an occasional basis, and substance ‘abuse’; chronic use or dependence on a substance or substances.

Although the latter may appear to cause more health related problems, the former can also have direct impact on health services, through the same avenues of crime, accidents, impulsive behaviour and mortality rates. These health consequences occur from behaviour such as driving under the influence of drugs and being predisposed to accidents, domestic violence, rapes and sexual abuse, risky sexual behaviour, suicidal attempts and self harm, child abuse may all be associated with substance use. These then impact on health care and social costs. Substance abuse is a health disorder and therefore can be categorized as a disease and is categorized as a mental disorder by international classificatory systems [7]. It is associated with multiple organ pathology with increased risks for cancer, organ failures, heart and central nervous system disease and HIV/AIDS through reckless sexual behaviour that occurs either in search of, or in the aftermath of, drug use [4,5]. Domestic and interpersonal violence, road traffic and other accidents, crime, diminished productivity, utilisation of scarce economic resources and the multiple negative health consequences of problematic drug use demand a public health approach to generate improved methods of addressing the impact of these problems on affected communities [7].

The high prevalence rates of problematic substance use that is ‘substance use that creates unwanted harmful and deleterious effects on health and social functioning’ underline its relationship to public health as illustrated in the case of legal drugs like alcohol and nicotine. Traditional public health concerns of environmental safety, safe water supplies and adequate nutrition, have been replaced in the contemporary Western world by concerns related to lifestyle related problems of which problematic substance use must be acknowledged. The relationship of substance abuse to these lifestyle related diseases must also be appreciated as excessive use of alcohol and tobacco is associated with an increased risk for all of the chronic noncommunicable diseases [5,7].

A study here in Trinidad & Tobago found that up to 19% of mortality is directly attributable to substance use while a further 20% is indirectly related contributing to an overall 39% impact on mortality, with the 35-44 year age group being most at risk for substance use mortality, accounting for 26%, and males were found to be three times more likely to die from substance related causes than females [8]. There is also the impact on pregnancy and childbirth where children born to women who abuse substances are likely to have a lower average birth weight.

This lower than average birth weight is itself associated with a variety of negative health consequences for the affected 27

Caribbean Medical Journal SUBSTANCE ABUSE AS A PUBLIC HEALTH PROBLEM

children, including an increased risk of substance abuse problems themselves in adulthood [9].

Alcohol Lifetime prevalence rates of alcohol use in the adult population are in the range of 75-85% in Trinidad and Tobago and up to 43% in adolescents (10) and while no population study has investigated the prevalence of alcohol abuse and dependence, Trinidad and Tobago has over 112 Alcoholics Anonymous Groups making it one of the countries with a high per capita membership greater for example than in the United Kingdom [11]. In recognition of the global health burden of alcohol use, the World Health Assembly in 2010 adopted a resolution to embark on a global strategy to reduce the harmful effects of alcohol [12]. This resolution highlighted the need for a heightened global awareness of the health related problems of alcohol use and the need for a political commitment to implement evidence based alcohol control strategies [13]. These include limits on availability, restrictions on marketing, taxation and pricing policies to discourage frequent and heavy alcohol consumption, measures to control social contexts that promote excessive drinking and reducing the availability of illicit and informally produced alcohol [4, 13]. The risk of injuries presenting to hospital, secondary to domestic violence, is greatest when the partner has alcohol related problems [14]. Alcohol use and dependence is also associated with increased use of emergency health services [15].

later years. It may also be associated with depression and suicidal behaviour in adolescence [21]. A recent study in Canada has also shown acute cannabis consumption to be associated with an increased risk of motor vehicular accidents particularly fatal ones [22]. According to the World Drug report [23] the annual prevalence of cannabis use in Trinidad and Tobago is 4.7% compared to a Caribbean average of 9%. Cannabis was also the most common drug found in homicide victims (32%) compared to alcohol (29%) and cocaine (7%). This reflected an increase between 2001 and 2007 [24].

Cocaine Cocaine use began in the late 1970s in Trinidad and Tobago and escalated into the 1980s prompting the establishment of the Substance Abuse and Prevention Treatment Centre in Caura.

Cocaine is associated with significantly increased risk for developing abuse and dependence related problems and is often associated with criminal behaviour and homelessness [25].

Cocaine and other stimulant drug use are associated with cardiomyopathy, particularly after long term use [26]. This may give rise to sudden cardiac events and death. This risk is significantly increased when there is use of cannabis and alcohol as in the poly drug user/abuser [27].

Nicotine A study in the United States has shown that the major disparities in life expectancy within the population there are due to smoking and high blood pressure. In other words, if less people smoked and controlled their blood pressure there would increased life expectancy among all population groups in the United States [16]. This is the primary burden of tobacco or nicotine use, its impact on cancer and cardiovascular and cerebrovascular disease.

In Trinidad and Tobago, it is estimated that between 15- 20% of the population smoke regularly with the male to female ratio being approximately 2:1 though there is evidence that among the youth, this ratio is in decline as more females are smoking regularly ([7, 18).

Cocaine use is also associated with deaths due to homicide and HIV/AIDS and while these deaths may be indirectly caused through the facilitation of high risk behaviour, they constitute a real contribution to the deaths associated with substance use.

Risky sexual behaviour is associated with substance use and therefore with an increased risk for the transmission of sexually transmitted diseases including HIV/AIDS [26]. In Brazil, crack cocaine use has been found to be predominantly associated with homicidal death in the young adult population [28].

Since its most popular current use is in the form of crack cocaine, which is smoked, it can also be a cause of lung pathology . Its use also worsens the outcome of many medical conditions [29].

The social consequences are also great with regard to the compromised development process when the young and middle adult group are affected by cocaine use. This applies to both users and their relatives who have a much more demanding caregiving role [25].

Cannabis Cannabis is the most commonly used illicit drug in the Western world. There has long been a debate about its potential for causing mental health problems. It has been found to be associated with depression in adolescence and with psychosis. Low self control, externalizing behaviour and sensation seeking are associated with maintaining marijuana use from adolescence to adulthood [19]. Another recent study shows that cannabis use causes individuals to develop psychosis (losing touch with reality) 3 years earlier than non cannabis users [20]. Additionally, there does seem to be a direct causal effect on the development of psychosis, presumably by a neurotoxic mechanism. The risks of using cannabis must be spelt out more clearly to young people. As a substance that is smoked, it may also be associated with mouth, throat and lung conditions. It is especially important to target the youth as they are most easily influenced and attracted by the use of cannabis. Any public health program must incorporate an appreciation of the risks of cannabis use. Early cannabis use in adolescence seems especially likely to contribute to increasing the risk of subclinical and clinical psychosis in

HIV/AIDS Another interesting association was the relationship between deaths from HIV/AIDS and other infectious illnesses and substance use. Certainly it is well known that substance use increases risky sexual behaviour and predisposes them to contracting sexually transmitted diseases but it appears that it also further compromises the immune system and makes them more likely to suffer fatal consequences of these infectious diseases [28]. For example, HIV/AIDS is a major concern in Trinidad and Tobago with the incidence of new cases increasing every year and projected to rise to 2% by 2012, and with a marked difference in the number of female cases presenting [30]. In the US one in four of those living with HIV in 2009 reported use of alcohol or drugs at a level that warranted treatment [31] Although there is relatively little injected drug use in Trinidad and Tobago and the Caribbean, cocaine abuse and dependence has been strongly associated with a greater risk for contracting HIV infection [32]. The mechanism for this remains unclear but may be related to impaired judgment informing high risk sexual behaviour. It may also cause individuals seeking

28

Caribbean Medical Journal SUBSTANCE ABUSE AS A PUBLIC HEALTH PROBLEM

the drug to use sexual activity as a menas of obtaining it. Further, individuals who take drugs or engage in high-risk behaviors associated with drug use also put themselves and others at risk for contracting a range of other infectious diseases including hepatitis C (HCV), hepatitis B (HBV), and tuberculosis (TB), as well as a number of sexually transmitted diseases including syphilis, chlamydia, trichomoniasis, gonorrhea, and genital herpes [31].

Homelessness Some authors suggest that while substance abuse may not directly lead to homelessness, it is attributed to the disaffiliation a person has with society and is therefore inextricably tied to the breakdown of bonds within communities [32]. Those living on the streets have increased health problems, regardless of their use of substances, but more interestingly they note the link between substance abuse and the breakdown in community cohesion. Again this highlights a familiar pattern where, there is a bidirectional relationship between societal breakdown and substance abuse. This occurs because when societies breakdown, substances use increases, but the increase of substance use in itself is also partly responsible for the breakdown in both family and community bonds [33].

Improved service provision and policy initiatives to address social disorganisation are key in the development of strategies to combat the health and social problems associated with substance use [34]. Substance abuse weakens the bonds that hold families together and therefore affect the societyâ&#x20AC;&#x2122;s capacity to provide adequate support to its weaker members thereby facilitating social disorganisation. Particularly in poorer communities where social disorganisation is more acute and substance abuse seems to be more prevalent there is a urgent need to improve healthcare services tailored to the needs of the community, providing increased health related education.

Unemployment is also related to substance use as are, increased sick leave and decreased productivity for both the afflicted and their relatives and friends. This then increases disparities in health and socio-economic status as well foster broken homes and and developmental problems for young people growing up in these homes [35]. This is especially relevant for small, developing countries although the example comes from the United States where half to two thirds of prison inmates have been found to have diagnosable alcohol or drug abuse/ related condition or a mental illness [36]. Again evidence suggests that drugs and substance abuse in a variety of contexts, are related to crime and if these substance problems are not dealt with effectively they increase. There is also another major underrecognised public health issue related to incarceration among those with substance abuse problems and that is HIV infection which needs to be addressed in order to assist wth diminishing the health burden of both problems in the society [37].

Special Populations Evidence suggests that children who suffer physical and sexual abuse and emotional neglect, most notably females, are at a significantly higher risk of developing substance abuse and dependency problems and well as issues with crime and violence as they grow up [38]. This then perpetuates a vicious pattern of repeated cycles which will only increase the need for appropriate health resources as the patterns are continued and passed from

generation to generation. There are also multiple social problems that may be transmittted across generations, these include homelessness, decreased education uptake, decreased performance and an increased risk of incarceration. Further, there is increasing evidence that a health orientated approach to substance abuse is the most effective way of, not only decreasing the numerous health related problems in society, but also of effectively decreasing the illicit drug trade (34), which is endemic in Trinidad & Tobago. A comparative study of gangs in Trinidad and Arizona found that gang membership among adolescents in Trinidad was predicted by the intention to use drugs which was not so for their counterparts in Arizona. There was also more violent behaviour by the gang members in Trinidad [39, 40]. Drug use may the mediator of this finding.

Thus, managing accepting substance use as a public health problem first and foremost, before defining it as an issue of crime, would help create more effective prevention and intervention strategies that could play a pivotal role in changing the face of gang activity and ultimately decreasing drug related crime [12]. This also impacts indirectly on health as fear of crime and fears about public security are also related to drug use, gangs and an increased presence of guns.

Strategies One of the best strategies to address these problems should start with adolescent substance use. National surveys in Trinidad and Tobago have found levels of alcohol and drug use ranging from 42- 85% [10, 23, 25]. There are two broad areas that can be used to deal with substance use in this age group; firstly, control of societal and cultural factors [41], which can be very powerful in Trinidad and Tobago in encouraging drug use.

Social and advertising images of what is seen as acceptable and necessary for social conformity influence the use and possible abuse of alcohol, nicotine and illicit drugs [42, 43]. Further when there is prevalence of drugs in the home, whether it be parents or siblings, children will imitate the actions of the parents and frequently the parents will allow or even induce the use of substances in their children [10] as in the recent death of a two year old child in Trinidad who was given beer to drink [44]. Evidence shows that children using substances from a young age have a higher risk of continuing and worsening substance abuse during their lifetime [1, 45]. In order to change these cultural patterns of acceptance, we need to reorient people, especially younger people, particularly in relation to the health problems they are potentially risking and begin to create a different image of substance use. There are also lax laws and relatively little social questioning in relation to alcohol and drug use. Laws, particularly those related to access to alcohol and cigarettes for minors need to be more effectively implemented so that access to substances is dramatically reduced.

The second category to address are those related to interpersonal environments and interaction [41]. The primary interpersonal environments implicated and requiring intervention are the peer group and the home environment. Peer group behaviour and parental behaviour strongly interact and influence adolescent drug use as weak and absent parental supervision and involvement promote stronger peer group influences [45]. More permissive homes where there is more alcohol and cigarette use, more religious homes and those with easy availability of guns also have more illicit drug use [46]. Antisocial behaviour and high residential mobility are also associated with adolescent 29

Caribbean Medical Journal SUBSTANCE ABUSE AS A PUBLIC HEALTH PROBLEM

substance use and gang membership [40] and programs to address these issues must therefore focus on peer groups and parents as points of intervention if substance use at this age is to be controlled. Using a public health approach, improving access to mental health and addressing a wide range of social and health disparities is likely to have a positive effect on the society’s health and general functioning. The medical profession has to play its role in advocating for the use of its resources to deal with the problems associated with substance use and abuse and capitalize on the likely positive impact on crime and education to further attract resources to its cause.

REFERENCES 1. McCambridge J, McAlaney J, Rowe R. (2011), ‘Adult Consequences of Late Adolescent Alcohol Consumption: A Systematic Review of Cohort Studies’, PLoS Med 8(2): e1000413. doi:10.1371/journal.pmed.1000413.

2. National Institute on Drug Abuse (2011).Drug abuse and addiction: One of America’s most challenging public health problems. NIDA Http://archives.drugabuse.gov/about/welcome/aboutdrug abuse/magnitude/ 3. Russo P, Nastrucci C, Alzetta G, Szalai C (2011) Tobacco habit: historical, cultural, neurobiological and genetic features of people’s relationship with an addictive drug Perspectives in Biological Medicine ; 54(4): 557-577.

4. Room R, Babor T, Rehm J (2005) Alcohol and public health. Lancet, 365, 9458; 519-530.

5. Schulden JD, Thomas YF, Compton WM (2009) Substance abuse in the United States : findings from recent epidemiologic studies. Current Psychiatry Reports 11 (5) 353-359 6. Novick LF, Morrow CB. (2007), ‘Defining public health. Historical and Contemporary Developments. In Public Health Administration’. Manual for Population Based Management, eds Novick LF, Morrow CB & Mays GP., Jones and Bartlett Publishers, Massachusetts: 1-34.

7. Degenhardt L, Hall W. (2012) Extent of illicit drug use and dependence and their contribution to the global burden of disease. Lancet 379 (9810) ; 5570.

8. Hutchinson G. (2009), ‘A Study of Drug Related Mortality in Trinidad & Tobago (2003-2005)’,National Alcohol and Drug Abuse Prevention Programme (NADAPP), Government of the Republic of Trinidad and Tobago.

9. Substance Abuse and Mental Health Services Administration (2011), Results from the 2010 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-41, HHS Publication No. (SMA) 114658. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2011.

10. World Health Organisation (2004) Global Status Report on Alcohol. World Health Organisation, Geneva.

11. Peele S (1997) Utilizing Culture and Behaviour in Epidemiological Models of Alcohol Consumption and Consequences for Western Nations. Alcohol & Alcoholism, 32, 51-64,.

12. World Health Organisation (2010) Global strategy to reduce the harmful effects of alcohol. Geneva: World Health Organisaton : EB 126/2010/REC/2 13. Babor TF (2010) Public health science and the global strategy on alcohol.

Bulletin of the World Health Organisation, 88, 643-645.

14. Kyriacou, D.N., Auglin, D., Taliaferro, E., Stone, S., Tubb, T., Linden, J.A., Muelleman, R., Barton, E. & Kraus, J.F. (1999), Risk factors for injury to women from domestic violence. New England Journal of Medicine 341: 1882-1898 15. Dent A, Hunter G, Webster AP (2010) The impact of frequent attenders on a UK emergency department. European Journal of Emergency Medicine.

17 (6), 332-336.

16. Danaie G, Rimm EB, Oza S, Kulkarni SC, Murray CF, Ezzati M (2010) The promise of prevention: The effects of four preventable risk factors on national life expectancy and life expectancy disparities by race and county in the United States. PLoS Med, March 23; 7 (3) e10000248 17. Health Services Unit (2004) Tobacco Use survey. University of the West Indies, St Augustine sta.uwi.edu/ health/tobacco survey.htm 18. T r i n i d a d a n d To b a g o S m o k i n g P r e v a l e n c e ( 2 0 0 3 ) www.globalink.org/tccp/trinidad_tobago.pdf 19. Brook, JS; Zhang, C, Brook, DW (2011) Developmental trajectories of marijuana use from adolescence to adulthood: personal predictors, Archives of Pediatrics & Adolescent Medicine, 165(1):55-60 20. Large M, Sharma S, Compton MT, Slade T Niellsen O (2011) Cannabis use and an earlier onset of psychosis. A systematic meta-analysis. Archives of General Psychiatry 68 (6), 555-561.

21. Maharajh HD, Konings M (2005) Cannabis and suicidal behaviour in adolescents: a pilot study from Trinidad. Scientific World Journal, 5,576-585.

30

22. Asbridge M, Hayden JA Cartwright JL (2012) Acute cannabis consumption and motor vehicle collision risk. A systematic review of observational studies and metaanalysis. British Medical Journal, Feb 9; 344 e536: doi 10 1136/bmj.e536.

23. United Nations Office on Drugs and Crime (2006) World Drug Report 2006.

UNODC, New York 24. Kuhns JB, Maquire ER (2012) Drug and alcohol use aming homicide victims in Trinidad and Tobago 2001-2007. Forensic Science and Medical Pathology Jan. 13, epub ahead of print 25. Reid S.D. (2005) Substance Abuse. In Images of Psychiatry – The Caribbean.

Department of Psychiatry and Community Health, UWI, Mona, Eds. FW Hickling & E. Sorel, pp. 197-232. 2005.

26. Hser YI, Stark ME, Paredes A, Huang A, Anglin MD & Rawson R. (2006) A 12 year follow up of a cocaine dependent sample. Journal of Substance Abuse and Treatment 20 (3), 219-226.

27. Daisley H, Lecointe-Jones A, Hutchinson G & Simmons V (1999) Fatal cardiac toxicity temporally related to poly drug use. Veterinary and Human Toxicology 40 (1), 21-22.

28. Ribeiro M, Dunn J, Sesso R, Lima MS & Laranjeira R. (2007) Crack cocaine: a five year follow up study of treated patients. European Addiction Research 13 (1), 11-19 29. Cornish JW O’Brien CP (1996) Crack cocaine abuse : an epidemic with many public health consequences. Annual Review of Public Health 17, 259273.

30. United Nations General Assembly Special Session on HIV/AIDS (2010), ‘Country Progress Report: Trinidad & Tobago’. United Nations, New York 31. NIDA (2011), ‘InfoFacts: Drug Abuse and the Link to HIV/AIDS and Other Infectious Diseases’, http://www.drugabuse.gov/publications/infofacts/drugabuse-link-to-hivaids-other-infectious-diseases 32. Vageest, J. & Johnson, T. (2002), ‘Substance Abuse & Homelessness: Direct or Indirect Effects. Annals of Epidemiology, 12 (7), 455-461 33. Wallace, R. (1990), ‘Urban Desertification, Public Health and Public Order: 'Planned Shrinkage', Violent Death, Substance Abuse and AIDS in the Bronx’. Social Sciences & Medicine: 31(7): 801-13 34. United Nations Office on Drugs and Crime (2010), ‘From Coercion to Cohesion: Treating Drug Dependence through Health Care, Not Punishment’, UNODC, Vienna 35. Rich JD, Wakeman SE, Dickman SL (2011) Medicine and the epidemic of incarceration in the United States. New England Journal of Medicine, 364 (22), 2081-2083.

36. James DJ, Glaze LE (2006) Mental health problems of prison and jail inmates. Bureau of Justice Statistics, Washington ,DC Sep 2006.

37. Flanagan TP, Beckwith CG (2011) The intertwined epidemics of HIV infection, incarceration and substance abuse : a call to action. Journal of Infectious Diseases 203 (9), 1201-1203.

38. Widom, C. White, H. (1997), ‘Problem Behaviours in Abused and Neglected Children Grown Up: Prevalence and Co-occurrence of Substance Abuse, Crime and Violence’, Criminal Behaviour and Mental Health: Volume 7 (4), 287–310 39. Katz CM, Maguire ER, Choate D. (2011) A cross- national comparison of gangs in the US and Trinidad and Tobago. International Criminal Justice Review 21 (3), 243-262.

40. Katz CM, Fox AM (2010) Risk and protective factors associated with gang involved youth in Trinidad and Tobago. Rev Panam Salud Publica 27 (3), 187-202.

41. Hawkins, JD, Catalano, RF. Miller, JY (1992), Risk and protective factors for alcohol and other drug problems in adolescence and early adulthood: Implications for substance abuse prevention. Psychological Bulletin: 112, 64-105.

42. Berns GS, Chappelow J, Zink CF, Pagnoni G, Martin- Skurski ME, Richards J (2005) Neurobiological correlates of social conformity and independence during mental rotation. Biological Psychiatry 58 (3), 245-253.

43. Gibbons FX, Kingsbury J,Pomery EA, Gerrad M, Sargent JD, Chih-Yuen C, Wills TA, Dalcin S, Worth KA, Stoolmiller M, Transki SE, Hsiu-Chen Y (2010) Media as social influence : Racial influences in the effects of peers and media on alcohol cognitions and consumption. Psychology of Addictive Behaviours 24 (4), 649-659.

44. Asson C (2012) Child dies after drinking beer. Newsday, April, 12, 2012, www.newsday .co.tt 45. Kung EM , Farrell AD (2000) The role of parents and peers in early adolescent substance use: mediating and moderating effects. Journal of Child and Family Studies 9, 509-528.

46. Hemphill SA, Heerde JA, Herrenkohl I, Patton GC, Toumbourou JW, Catalano RF (2011) Risk and protective factors for adolescent substance use in Washington State, the United States and Victoria, Australia: a longitudinal study. Journal of Adolescent Health 49 (3), 312-320.

Caribbean Medical Journal

Audit A six year review of the head and neck cancers at the San Fernando General Hospital 2004 – 2009 G.Jugmohansingh MBBS, S. Medford FRCS, A. Boxill MBBS, P.Alexander MBBS, S.Giddings MBBS, P.Medford MBBS, C. Beharry MBBS, A. Alabli MBBS & S. Agarwal MBBS Department of Otolaryngology, San Fernando General Hospital, San Fernando, Trinidad.

Introduction Head and neck cancer is the sixth most common cancer worldwide accounting for 4% of cancers in men and 2% of cancers in women. [1] Squamous cell carcinoma represents more than 90% of these cancers. [2] There has been a steady increase in the incidence of head and neck cancers over the last couple of years (table 3). According to the American Cancer Society (ACS) statistics, the cases of head and neck cancers increased by approximately 25% during the years 2004 - 2008, where the overall new cancer cases only increased by about 5% in the same period. [3] [4] [5] [6] [7] This trend continued into 2009 with the estimated number of new cases in the United States being 35,720. [8] Though there are no recently recorded statistics for head and neck cancers in Trinidad, it would seem that the worldwide increase in cases is reflected by an apparent increase in the number of afflicted patients presenting to the San Fernando General Hospital.

Traditionally this type of cancer has been associated with heavy cigarette smoking and alcohol abuse [9],[10] The former is well established as a dominant risk factor with smokers having a lifetime risk that is 5- to 25-fold increased over the general population. [11] The risk is correlated with the intensity and duration of smoking. Head and neck cancer is also strongly associated with certain occupational exposures. [12] A number of minor risk factors have also been documented.

Over the last few years at the San Fernando General Hospital, it was observed that there was an increased incidence of head and neck cancers within a younger age group. It also seemed that cancers were increasing amongst the non-smoking, nonalcohol consuming patients. This audit was carried out to determine if these assumptions were true. The files of all the confirmed head and neck cancer patients between the years 2004 – 2009 at the San Fernando General Hospital were retrieved and examined.

Methods The records of patient admissions and discharges from the Otorhinolaryngology department at the San Fernando General Hospital between the years 2004 – 2009 were reviewed. The files of all the patients who had a diagnosis of a head and neck cancer or had symptoms suggestive of such were retrieved and examined. A standard questionnaire was used to obtain the necessary information. Only histologically confirmed head and neck cancers were included in the study. Thyroid cancers, oesophageal and eyelid cancers though treated by the department were excluded from the study. Patients who had a diagnosis of a benign tumour or a lymphoma were also excluded.

After obtaining the relevant hospital files, lists were then made.

These lists were frequently reviewed to ensure that duplication of file numbers did not occur and that patients were analysed

according to their appropriate years. Patients were classified according to the date they presented to the San Fernando General Hospital with symptoms and not the year that the cancer was confirmed.

Results Out of a total of a 104 possible cases, 99 confirmed cases were analysed. Files were not found for 15 patients. On average, the amount of new head and neck cancer cases presenting annually to the ENT Surgical department between the years 2004 – 2009 was 16.

Approximately two thirds of the cancer patients were male and the remaining one third was female (67 and 23 respectively).

East Indians represented 47.5%, Africans 32.3% and 9.1% were of mixed of ethnicity.

Head and neck cancers occurred in three patients who were younger than twenty years. The youngest documented was seventeen years old. However, the incidence of cancer increased significantly from the age of 40. It decreased after this but still remained higher than the incidence within the 20 – 29 group.

Laryngeal and tongue cancers were the most common cancer types, accounting for 25.3% and 24.2% of cases respectively.

This was followed by oropharyngeal cancer (10.1%), hypopharyngeal cancer (5.1%), nasopharyngeal cancer (5.1%), parotid cancer (4.0%), paranasal sinus cancers (4.0%), maxillary cancer (4.0%), nasal cancer (3.0%) and minor salivary gland cancer (2.0%). Cancers of the mandible and ear accounted for 1% each.

Cancers of unknown origin accounted for 2% of patients. These cases were confirmed from biopsies of cervical nodes. Therefore it was assumed that the primary cancer originated within the head and neck region. These patients had died before investigations for the primary site of origin could be completed.

The families had refused post mortems.

31

Caribbean Medical Journal A SIX YEAR REVIEW OF THE HEAD AND NECK CANCERS AT THE SAN FERNANDO GENERAL HOSPITAL 2004 – 2009

Table 1. Total number of cancers according to gender, ethnicity and social habits Cancer

Male

Female

Ethnicity

Cigarettes Alcohol

Laryngeal

24

1

11EI, 11A 2M

18

16

Tongue

19

5

15EI, 5A, 3M

13

15

Oropharynx

8

2

4EI, 5A

7

7

Hypopharynx

3

2

2EI,2A,1M

3

4

Nasopharynx

2

3

4A, 1M

2

2

Nasal

2

1

3EI

-

1

Paranasal sinuses

1

3

3EI,1A

-

1

Parotid

2

2

4EI

-

2

Minor salivary 2

0

1 EI,1M

1

-

Maxillary

2

2

2EI,1A, 1M

1

2

Mandibular

1

0

1A

-

-

Ear canal

0

1

1EI

Unknown primary

2

0

2A

1

1

*EI – East Indian, A – African, M – mixed

Table 2. Total number of cancer cases per year according to gender and social habits 2004

2005

2006

2007

2008

2009

Confirmed cases

15

21

11

18

18

7

Males

12 50% (S) 50%(A)

12 58.3%(S) 83.3%(A)

7 16 15 5 57.1%(S) 62.5%(S) 73.3%(S) 80%(S) 85.7%(A) 68. 8%(A) 73.3%(A) 80%(A)

Females

3 0 %(S) 0% (A)

9 4 33.3% (S) 0(S) 0% (A) 0(A)

2 50%(S) 50%(A)

3 2 33.3%(S) 0%(S) 33.3%(A) 0%(A)

steadily increasing worldwide.[3-7] The Otorhinolaryngology department of the San Fernando General Hospital diagnoses an average of sixteen new head and neck cancer cases per year.

These patients, together with those who were diagnosed in the previous years contribute to more than thirty cancer patients accessing healthcare in the department simultaneously each year.

Internationally, 66 - 95% of head and neck cancers occurred in men. [14] This is in keeping with the findings of this audit in which 67.7% of cancers were male. Women are two to three times less likely to develop head and neck cancer. This remained true in this audit except for the year 2005 in which females accounted for 42.9% of cancer patients.

East Indians are primarily descendants from indentured workers from India. They make up 40% of the population. Africans account for 37.5%, mixed ethnicity 20.5%, others 1.2% and unspecified 0.8%. [15] In this audit, 47.5% of cancers occurred in east indians. This represents a small increase in cancer cases in this group compared to the general population. Head and neck cancers occurred in 32.3% of africans and 9.1% of patients with mixed ethnicity. In the mixed ethnicity category, there was a lower incidence of head and neck cancers compared to the general population. The reason is unclear.

Though head and neck cancers did occur in patients within the age groups <20 and 20 – 29 years old, the majority of cases occurred in the older age groups (40 – 69 years). This is in keeping with international figures. No similarities were observed amongst these patients except for the absence of an alcohol and cigarette smoking history. As the study was retrospective, detailed histories were not obtained and as such other causes could not be documented. Worldwide though, the increase in head and neck cancers in the younger age is being attributed to specific viruses like the human papilloma (HPV) and the Epstein Barr virus. Over the past 15 years, HPV has been etiologically linked with oropharyngeal cancers. The true prevalence remains uncertain, yet studies have estimated that up to 60% of HNSCCs may be HPV positive [16,17]

* S – smoking, A - alcohol

Combining all the years, the total number of male patients who smoked cigarettes was 42. This accounted for 62.7% of all male patients. The number of males consuming alcohol was 48; accounting for 71.61%. The total amount of female patients who smoked was 5 accounting for 21.7%. Two female patients consumed alcohol accounting for 8.7% of all female patients.

The overall smoking statistics demonstrated an almost equal distribution of cancers between smokers (47.5%) and nonsmokers (40.4%).The overall alcohol statistics indicated an increased amount of cancers in patients who consumed alcohol (50.5%) compared to patients who did not (37.4%).

Within the <20 age group, it was observed that all of the three patients did not smoke or use alcohol. There were no other documented similarities.

Discussion Head and neck cancers account for approximately 3 - 5 % of all cancers in the United States. [13] Though this represents only a small fraction, the incidence of this type of cancer has been 32

The most common head and neck cancer with which patients presented to the San Fernando General Hospital was laryngeal cancer (supraglottic, glottic and subglottic cancers). This cancer is actually listed as a "rare disease" by the Office of Rare Diseases of the National Institutes of Health. [18] There were 25 cases of laryngeal cancers documented from 2004 - 2009.

Smoking is the most important risk factor for this cancer and 72% of audited patients were smokers. The consumption of alcohol is also significant and 64% were consumers of alcohol.

Constant exposure to these agents over a long period of time is needed for the development of cancer. This may explain why cancers occurred within the older age groups (20% in the 40 – 49 group, 20% in the 50 – 59 group, 36% in the 60 – 69 age group and 12% in the 70 – 79 age group). Male sex is also a risk factor for the development of laryngeal cancer. However, it should be noted that in this audit male patients smoked and abused alcohol the most.

Twenty four cases of tongue cancer were documented. Tongue cancers are common in the developing world, particularly Southeast Asia and Brazil. The incidence of this type of cancer

Caribbean Medical Journal A SIX YEAR REVIEW OF THE HEAD AND NECK CANCERS AT THE SAN FERNANDO GENERAL HOSPITAL 2004 – 2009

depends on etiologic factors some of which include smoking, betel use (betel leaf, and often tobacco, plus spices, calcium hydroxide, and areca [betel] nut) and alcohol consumption.[19] In this audit, patients who smoked represented 54.2% and those who consumed alcohol accounted for 62.5%. 19.2% of these patients were male. 62.5% were East Indians.

There were ten cases of oropharyngeal cancer documented.

Worldwide, the human papilloma virus has been implicated in the increasing incidence of these cancers.[16,17] Most HPV-related oropharyngeal cancers are due to infection with the HPV 16 subtype.[20, 21] Sexual behaviors as well as open mouth kissing are important routes of exposure to oral HPV infection.[22] Most oropharyngeal cancers that are not caused by HPV infection are due to tobacco and alcohol use. [23] In this audit, 70% of these patients both smoked and consumed alcohol. The majority of cancers still occurred in the older age groups.

Hypopharyngeal cancers represent approximately 7% of all cancers of the upper aerodigestive tract in the United States.

There were five cases documented. Patients have a history of tobacco use, alcohol ingestion or both. In this audit, 60% of patients smoked cigarettes and 80% consumed alcohol. There is also an increased incidence of postcricoid cancer in women aged 30-50 years with Plummer-Vinson syndrome. [24,25] The role of the human papilloma virus (HPV) in cancers of the hypopharynx is unclear.

There were five cases of nasopharyngeal cancer. In the United States, the incidence of nasopharyngeal carcinoma is increased among black teenagers, children of Asian, Middle Eastern and Northern African descent.[26] In this study, 80% of cases occurred within the African population whereas 20% occurred within the mixed ethnicity. No East Indians were affected. Usually, it has a bimodal age distribution - a small peak in late childhood and a second peak in people aged 50-60 years. This was reflected in the audit with 20% occurring in the <20 age group and the majority of cases (80%) occurring amongst the 50 – 59 age group. It is most strongly associated with Epstein-Barr virus infection.[27] However, viral studies were not performed on the patients in this study. Smoking and alcohol usage was found in 40% of patients.

Malignant tumours of the nasal cavity are often grouped with tumours of the paranasal sinuses. There were 3 nasal cancers and 4 cases of paranasal sinus cancer. Two of the nasal cancers occurred in men and 1 in women. 100% were of East Indian descent. Two occurred in the 40 – 49 age group and one in the 50 – 59 group. None of the patients smoked cigarettes and one consumed alcohol.

There were 4 cases of paranasal sinus cancers. The specific sinuses where the cancers originated were not well documented.

1 was male and 3 were female. This did not correlate well with international figures but was most likely due to the small number of patients in this group. 3 were east indians whereas 1 patient was african. In this audit, paranasal sinus cancers started developing at an earlier age than nasal cancers. One occurred in the 20 – 29 age group, one in the 40 – 49 group, one in the 60 – 69 group and one in the >80 group. None of the patients who developed cancer of the paranasal sinuses smoked cigarettes and only one consumed alcohol. Tobacco smoking is not

considered to be a significant etiologic factor for this cancer, however, recent studies demonstrate a higher incidence of nasal cancers in cigarette smokers.[28,29] The more significant risk factors include: wood dust, leather dust, nickel and chromium compounds.[30] Salivary gland cancer is rare, with 2% of head and neck tumors forming in the salivary glands - the majority in the parotid.[29] Four parotid cancers were identified. In the literature, peak incidence is documented to occur between 30 - 50 years. In this audit: one patient was less than 20 years, one was within the 20 – 29 age group, one in the 50 – 59 group and one in the >80 group. The number of patients is too small to arrive at any significant conclusions. All patients were of east indian descent.

No one smoked cigarettes. Existing data regarding the relationship between smoking and salivary gland tumours are sparse and tobacco is not currently classified as a salivary gland carcinogen. There is however an association between consumption of alcohol and parotid cancers.[31] Two patients consumed alcohol. Only 2 cases of minor salivary gland tumours were documented - both occurred in the year 2005.

Currently, an estimated 19.3% of all adults (aged 18 years or older) in the United States smoke cigarettes. Men accounted for 21.5% and women 17.3%.[32] No recent statistics regarding cigarette smoking for Trinidad and Tobago were found at the time of this audit. The last documented local smoking statistics done in 1989 had estimated the percentage of men who smoked cigarettes to be 42.1% and women to be 8%.[33] It is suspected that the current local statistics for men remain higher than the international values.

It has been documented that exposure to environmental tobacco smoke may increase the risk of head and neck cancer with a dose-response pattern.[34] Also, a recent epidemiological study showed that marijuana smoking was associated with an increased risk of head and neck cancer.[35] Though illegal, its use in Trinidad and Tobago is fairly common and it may be the second most commonly smoked substance after tobacco. Information regarding second hand smoking and marijuana usage was not documented in this audit.

In 1995, heavy drinking (at least 21 units per week) was reported by 10.5% of males in Trinidad.[36] A study conducted in Tobago found that CAGE responses consistent with alcoholism were present in 14.3% of males and 1.1% of females. [37] The overall alcohol statistics in this audit revealed much higher percentages of alcohol use compared with what was seen in the earlier years.

Alcohol abusers accounted for 50.5% of cancer patients in the audit.

Conclusion Ninety nine confirmed cases of head and neck cancer were analysed. The ENT department of the San Fernando General Hospital has been diagnosing an average of 16 new cases per year from 2004 - 2009. However, as a result of the small number of patients in each cancer subgroup, it is very difficult to draw any significant conclusions from the observations made.

Most head and neck cancers occurred in the older age groups - except for the four patients with parotid cancer. However, the number of patients is too miniscule to draw any significant conclusions. The overall statistics demonstrated an almost equal distribution of cancers between smokers and non-smokers. The 33

Caribbean Medical Journal A SIX YEAR REVIEW OF THE HEAD AND NECK CANCERS AT THE SAN FERNANDO GENERAL HOSPITAL 2004 – 2009

overall alcohol statistics demonstrated a similar pattern. In this study due to insufficient documentation in the patient files, smokers and alcohol users could not be classified as mild moderate or heavy users.

The most common cancer with which patients presented to the hospital was laryngeal cancer. This was followed by tongue, oropharyngeal, hypopharyngeal, nasopharyngeal, parotid, paranasal sinuses, maxillary, nasal, minor salivary glands, head and neck cancers of unknown primaries, mandibular and ear canal cancers.

Acknowledgments Dr. Rabindranath Maharaj. Gulf View Medical Center. Trinidad and Tobago Competing interests None declared Corresponding Author Dr. G. Jugmohansingh, Department of Otolaryngology, San Fernando General Hospital, San Fernando, Trinidad.

Table 3 Head and neck cancer statistics based on American Cancer Society Year 2004 2005 2006 2007 2008

Cancer Statistics 2004, 2005, 2006, 2007, 2008 [3–7] All cancers (U.S) Head and neck cancer (New) 1,368,030 28,260 1,372,910 29,370 1,399,790 30,990 1,444,920 34,360 1,437,180 35,310

REFERENCES 1. Boring, C. C, Squires, T. S, and Tong T. Cancer statistics, 1991. CA Cancer J. Clin., 41: 19–36, 1991.

2. NCI factsheet on head and neck cancer 3. A. Jemal, R. C. Tiwari, T. Murray, et al., “Cancer statistics, 2004,” CA: A Cancer Journal for Clinicians, vol. 54, no. 1, pp. 8–29, 2004.

4. A. Jemal, T. Murray, E. Ward, et al., “Cancer statistics, 2005,” CA: A Cancer Journal for Clinicians, vol. 55, no. 1, pp. 10–30, 2005.

5. A. Jemal, R. Siegel, E. Ward, et al., “Cancer statistics, 2006,” CA: A Cancer Journal for Clinicians, vol. 56, no. 2, pp. 106–130, 2006.

6. A. Jemal, R. Siegel, E. Ward, T. Murray, J. Xu, and M. J. Thun, “Cancer statistics, 2007,” CA: A Cancer Journal for Clinicians, vol. 57, no. 1, pp.

43–66, 2007.

7. A. Jemal, R. Siegel, E. Ward, et al., “Cancer statistics, 2008,” CA: A Cancer Journal for Clinicians, vol. 58, no. 2, pp. 71–96, 2008.

8. Estimated New Cancer Cases and Deaths by Sex, US, 2009 9. W. J. Blot, J. K. McLaughlin, D. M. Winn, et al., “Smoking and drinking in relation to oral and pharyngeal cancer,” Cancer Research, vol. 48, no.

11, pp. 3282–3287, 1988.

10. Spitz M (1994). "Epidemiology". Semin Oncol 21 (3): 281–8.

11. Andre K, Schraub S, Mercier M, Bontemps P (1995). "Role of alcohol and tobacco in the aetiology of head and neck cancer: a case-control study in the Doubs region of France". Eur J Cancer B Oral Oncol 31B (5): 301–9.

12. Ridge JA, Glisson BS, Lango MN, et al. "Head and Neck Tumors" in Pazdur R, Wagman LD, Camphausen KA, Hoskins WJ (Eds) Cancer Management: A Multidisciplinary Approach. 11 ed. 2008.

13. National Cancer Institute. Cancer Topics [homepage on the internet]. Harold Varmus : US National Institutes of health; cited on 2010 Aug 22. Available from : http // www.cancer.gov/ 14. Ridge JA, Glisson BS, Lango MN, and Feigenberg S. Head and neck tumors. In: Pazdur R, Wagman LD, Camphausen KA, Hoskins WJ, editors.

Cancer Management: A Multidisciplinary Approach, 12th Edition (2009) D'Souza, G.; Kreimer, A.; Viscidi, R.; Pawlita, M.; Fakhry, C.; Koch, W.; Westra, W.; Gillison, M. (May 2007). "Case-control study of human papillomavirus and oropharyngeal cancer". The New England journal of medicine 356 (19): 1944–1956.

15. http://www.indexmundi.com/trinidad_and_tobago/demographics _profile.html. Retrieved 2012-04-05 16. Smith EM, Ritchie JM, Summersgill KF, et al. Age, sexual behavior and human papillomavirus infection in oral cavity and oropharyngeal cancers.

Int J Cancer 2004;108:766–72.

17. Franceschi S, Munoz N, Bosch XF, Snijders PJ, Walboomers JM. Human papillomavirus and cancers of the upper aerodigestive tract: a review of epidemiological and experimental evidence. Cancer Epidemiol Biomarkers Prev 1996;5:567–75.

18. Yuan JM, Wang XL, Xiang YB, Gao YT, Ross RK, Yu MC. Preserved foods in relation to risk of nasopharyngeal carcinoma in Shanghai, China. Int J Cancer. Feb 1 2000;85(3):358-63.

19. S Crispian, P Stephen. Oral cancer. West J Med. 2001 May; 174(5): 348–351 20. Kreimer AR, Clifford GM, Boyle P, Franceschi S. Human papilloma virus typesIn head and neck squamous cell carcinomas worldwide: a systematic

34

review. Cancer Epidemiol Biomarkers Prev 2005;14(2):467-75.

21. Chaturvedi AK, Engels EA, Anderson WF, Gillison ML. Incidence trends for human papillomavirus related and -unrelated oral squamous cell carcinomas in the United States. J Clin Oncol 2008;26(4): 612-9.

22. D’Souza G, Kreimer AR, Viscidi R, et al. Case-control study of human papillomavirus and oropharyngeal cancer. N Engl J Med 2007;356(19): 1944-56.

23. Franceschi S, Talamini R, Barra S, et al. Smoking and drinking in relation to cancers of the oral cavity, pharynx, larynx, and esophagus in northern Italy. Cancer Res1990;50(20): 6502-7.

24. Larsson LG, Sandström A, Westling P. Relationship of Plummer-Vinson disease to cancer of the upper alimentary tract in Sweden Cancer Res. 1975 Nov;35(11 Pt. 2):3308-16.

25. Anderson SR, Sinacori JT. Plummer-Vinson syndrome heralded by postcricoid carcinoma. Am J Otolaryngol 2007 Jan-Feb;28(1):22-4.

26. Richard Cote, Saul Suster, Lawrence Weiss, Noel Weidner (Editor) (2002).

Modern Surgical Pathology (2 Volume Set). London: W B Saunders.

27. Zimmer LA, Carrau RL. Neoplasms of the nose and paranasal sinuses. In: Bailey BJ, Johnson JT, Newland SD, eds. Head & Neck Surgery Otolaryngology. 4th. Lippincott, Williams & Wilkins; 2006.

28. Benninger MS. The impact of cigarette smoking and environmental tobacco smoke on nasal and sinus disease: a review of the literature. Am J Rhinol. Nov-Dec 1999;13(6):435-8.

29. Harari, Paul (2009). Functional Preservation and Quality of Life in Head and Neck Radiotherapy. Springer.

30. d'Errico A, Pasian S, Baratti A, Zanelli R, Alfonzo S, Gilardi L, Beatrice F, Bena A, Costa GA case-control study on occupational risk factors for sino-nasal cancer. Occup Environ Med. 2009 Jul;66(7):448-55. Epub 2009 Jan 19.

31. Actis AB, Eynard AR (November 2000). "Influence of environmental and nutritional factors on salivary gland tumorigenesis with a special reference to dietary lipids". Eur J Clin Nutr 54 (11): 805–10.

32. Centers for Disease Control and Prevention. Vital Signs: Current Cigarette Smoking Among Adults Aged ≥ 18 Years—United States, 2005–2010.

Morbidity and Mortality Weekly Report 2011;60(33):1207–12 [accessed 2012 Jan 24].

33. UN (United Nations). 2001. World Database. Department of Economic and Social Affairs, Population Division. New York Population Prospects 1950-2050: The 2000 Revision.

34. Zhang ZF, Morgenstern H, Spitz MR, Tashkin DP, Yu GP, Hsu TC, Schantz SP. Environmental tobacco smoking, mutagen sensitivity, and head and neck squamous cell carcinoma. Cancer Epidemiol Biomarkers Prev. 2000 Oct;9(10):1043-9.

35. Zhang ZF, Morgenstern H, Spitz MR, Tashkin DP, Yu GP, Marshall JR, Hsu TC, Schantz SP: Marijuana use and increased risk of squamous cell carcinoma of the head and neck. Cancer Epidemiol Biomarkers Prev 1999;8:1071-1078.

36. Health in the Americas. Pan American Health Organization, 1998 Edition.

37. Patrick AL et al. Alcohol consumption patterns in two Caribbean islands: the CAGE Questionnaire as a predictor of mortality. West Indian Medical Journal, 1996, 45(Supplement 2):34

Caribbean Medical Journal

Commentary Family Medicine, CCFP, Wonca and Trinidad & Tobago Sonia Roache-Barker MBBS, FCCFP Introduction The discipline of Family Medicine has now been deemed a medical specialty in its own right by the medical profession and many young members of the T&TMA have completed the postgraduate programme in Family Medicine , having chosen that career path. As defined by Wikipedia, Family medicine (FM) is a “medical specialty devoted to comprehensive health care for people of all ages. It is a division of primary care that provides continuing and comprehensive health care for the individual and family across all ages, sexes, diseases, and parts of the body. It is based on knowledge of the patient in the context of the family and the community, emphasizing disease prevention and health promotion”.

Wonca (World Organization of Family Doctors) Family doctors like to think of themselves as the “Consultant for the Patient”, the “conductor of a primary care team that coordinates the care of the whole patient” and according to the World Organization of Family Doctors (Wonca), “the aim of family medicine is to provide personal, comprehensive and continuing care for the individual in the context of the family and the community, from cradle to the grave”.

Wonca is an acronym comprising the first five initials of the World Organization of National Colleges, Academies and Academic Associations of General Practitioners/ Family Physicians. For convenience, its name has been shortened to become the “World Organization of Family Doctors”.

Beginning with 18 members in 1972, one of which was the College of General Practitioners of India, there are now 120 member organizations in 100 countries and growing, and a total membership of over 250,000 general practitioners/ family physicians. This includes 10 organizations in collaborative relations with the world group.

The Caribbean College of Family Physicians (CCFP) started in 1989 as an ‘Organization in Collaborative Relations’ with Wonca, becoming a full member in 2004 after amendment of Wonca’s constitution to admit the College as a single entity representing a conglomeration of independent and nonindependent states from the Anglo, Dutch and Francophone Caribbean.

Wonca represents and acts as an advocate for its constituent members at an international level where it interacts with other world bodies. It has official relations with the World Health Organization (WHO) as a non-governmental organization and is engaged in a number of collaborative projects. Wonca supports the aims of its member organizations around the world, namely that of fostering and maintaining high standards of care in general practice/family practice; promoting personal , comprehensive, continuing care for the individual in the context of family and the community; encouraging and supporting the development of academic organizations of general practitioners/family physicians and represents the educational, research and service provision activities of general practitioners/family physicians in world fora concerned with

health and medical care. In so doing it seeks to empower its member organizations in improving the quality of life of the peoples of the world through defining and promoting the values of family medicine.

Wonca is run by a Council comprising the representatives of member organizations and officers elected from the seven(7) Regions of the world that constitute it- namely Africa, AsiaPacific, Eastern Mediterranean- Middle East, Europe, Iberoamericana-CIMF, North America & the Caribbean, SouthEast Asia. This Council meets formally every three (3) years to coincide with the Triennial World Conference of General Practitioners and Family Doctors. The last meeting of this kind occurred in May 2010 in Cancun, Mexico and the next is due to be held in Prague, Czech Republic in June 2013. Members of the Executive Committee meet twice per year to conduct the business of the organization and special committees, set up by the President, also hold meetings regularly throughout the three year period between council meetings, with a combination of face-to face meetings coinciding with regional meetings, online conferences and e-mails.

The Executive Committee members include the World President (presently Professor Richard Roberts, USA), the President Elect (Professor Michael Kidd, Australia), Immediate Past President (Professor Chris vanWeel, Netherlands), three (3) Membersat-Large, seven (7) Regional Presidents, the Editor and the CEO- World Secretariat. The Wonca World Secretariat initially located in Australia and managed for years by Professor Emeritus Wes Fabb and his wife Dr. Marian Fabb (both now retired), relocated to Singapore in May 2001. This has functioned since then under the able guidance of Dr. Alfred T. Loh (CEO) and his assistants Ms. Yvonne Chung (Administrative Manager) and Ms Gillian Tan (Accounts Executive). However, this situation will change in 2012 since Dr. Loh will be returning to his practice in Singapore.

Wonca publishes a Wonca Newsletter six times per year, available electronically; as also the European Journal of General Practice and he Asia-Pacific Family Medicine Journal, as well as a number of books and monographs. Its website www.globalfamilydoctor.com is managed from Australia by a special committee.

In seeking to continually encourage quality care in family medicine worldwide, and to encourage family doctors and general practitioners to continually give of their best, Wonca has instituted the “Global Family Doctor of the Month” and the Global Award of Excellence in Health Care "The 5-Star Doctor".

The first highlights the variations in family practice worldwide and rewards doctors who are doing great work under trying conditions and is presented monthly. The second and most prestigious is conferred on physicians, who in the opinion of the Council, have made a significant impact on the health of individuals and communities, through personal contributions to health care and the profession and is presented at

35

Caribbean Medical Journal FAMILY MEDICINE, CCFP, WONCA AND TRINIDAD & TOBAGO

each Triennial Conference . This originated as the brainchild of Dr. Boelen, World Health Organization Director following the Alma- Ata 1978 declaration on primary healthcare. WHO urged its Member States to ‘undertake coordinated reform in health care and in health professions practice and education, reorientation of medical education and medical practice for “health for all”’. Dr. Boelen stressed that ‘to fully respond to societal needs, medical schools must accept responsibility for the outcome of their deeds, and to institute three phases of "planning", "doing" and "impacting"’. He suggested that to achieve maximum impact there should be emphasis on producing a “5-star doctor” using these criteria for measurement of skills essential to he provision of the “doctor of the day-after –tomorrow” • Care provider • Decision-maker • Communicator • Community leader • Manager Nominations for this award are made regionally within Wonca and from these Regional awardees are chosen; finally from this group a Global award is given after voting at Council level.

The Caribbean College of Family Physicians (CCFP) The Caribbean College (CCFP) has managed to cop two of these awards since joining Wonca: •

The “Family Doctor of the Month” for May 2006 was Dr. Tomlin Paul, born in Morne Diablo, Trinidad , a graduate of the University of the West Indies, Mona and now a Senior Lecturer and researcher in the Department of Primary Care and Community Health at Mona and practising in Kingston, Jamaica.

•

In May 2010, in Cancun, Mexico, the “Global Five Star Award” was shared by Dr. Sonia Roache with Professor Ruth Wilson of Queens University, Canada, the first females to be so honoured. Dr. Roache was born in Manchester, Jamaica and practises in Port of Spain, Trinidad and is also attached to the Department of Family Medicine, St. Augustine Campus at Mt. Hope at her alma mater –UWI .

Impact of Wonca Wonca’s impact has been considerable world wide, notably in fostering he development of family medicine academic institutions particularly in areas where general practice/family medicine/ primary care traditionally had no voice or recognizable presence; in establishing working groups on many issues pertinent to family medicine such as the classification of problems encountered in general practice/ ambulant care; rural practice in underserved communities; quality assurance, research, medical informatics, education, communications and publications, health behaviour change, tobacco cessation, women and family in family medicine; respiratory diseases, chronic diseases, mental health- the list goes on. Special interest groups have been formed dealing with issues such as ethics, diagnostic challenges in primary medical care, care of the elderly, travel medicine, sports medicine, addictive behaviour; environment and its links to family medicine.

36

Groundbreaking studies carried out by members such as Professors Barbara Starfield , Ian McWhinney, Drs. Nicholas J. Pisacano , Jack Medalie and others ; by committees and organizations within Wonca have been published and have served to institute change at world health level- notably in the classification of diseases and conditions; in the delivery of health services, with increased focus on primary care and prevention; in the humane delivery of care – as for instance in the care of persons suffering from HIV-AIDS; in the management of the chronic diseases, mental illness and respiratory diseases; in equity of participation and organization in gender and other relationships; in bridging the gap between public health and family medicine.

Wonca members have many opportunities to meet and network at annual regional meetings and scientific congresses; at triennial world conferences and council meetings and also online at meetings of working parties or small interest groups set up and run by the members themselves. Members of working parties and small- interest- groups, all of which are open to any member of Wonca, look forward especially to he face- to- face meetings and personal reunions at regional and triennial conferences.

Regional conferences, numbering at least five (5) per year are held at various venues annually. Conferences planned for 2011 include the following venues: Warsaw, Poland; Hongkong ; Kuala Lumpur, Malaysia; Cebu, Phillipines; Mumbai, India; Dubai, UAE and Banff, Canada . Member organizations such as the AAFP (American Academy of Family Physicians), one of the largest individual member organizations within Wonca, ontinues to attract many family doctors to its annual congress usually held in the latter part of the year and Canada (CFPC) will hold its annual Family Medicine Forum in October in Montreal. These are conferences that the serious Caribbean GP/family doctor should try to attend at least once in his/her professional life.

Wonca has also convened meetings of young family doctors and residents, encouraging the formation of the Vasco da Gama movement in Europe, the Rajakumar movement in Asia-Pacific , the Latin American movement in Iberoamericana and most recently the Naffdona movement in North America. This has galvanized the attention of the younger doctors who aim to promote the discipline of general practice/family medicine through, inter alia : •

Providing a forum, support and information for trainees and young GPs through access to Wonca conferences and pre-conferences;

•

Establishing a communication network between trainees and young GPs across the world, identifying their concerns, doubts and needs and helping to address them. This will doubtless ensure that the vision and mission of Wonca will be sustained. Ironically, the young and future family doctors of the Caribbean, although invited to be part of the Naffdona movement have so far been apathetic in their response.

Wonca subscribes to the view that although all nations may not be able to afford to maintain the ideal complement of highly trained doctors, they can adopt the concept of family medicine

Caribbean Medical Journal FAMILY MEDICINE, CCFP, WONCA AND TRINIDAD & TOBAGO

for all their primary healthcare workers and in so doing they will be able to substantially improve the level of care and quality of life and general health of their citizenry, and by extension , the health of the world. CCFP joins with Wonca in believing that effective action in addressing the region's health problems is dependent on constant upgrading of the attitudes, knowledge and skills of the family physicians. The role of the College is to motivate and foster the pursuit of excellence in primary care through continuing medical education and professional development, cooperation and collaboration in training and research, and advocacy, by family physicians themselves. CCFP operates within each Caribbean territory in harmony with the various local medical associations, encouraging members not only to join but to become active participants in their local medical association’s activities. By-laws that govern the College

allows for “Observer status” on the Board of Directors of the College to be granted on request to each local medical association.

The Trinidad & Tobago Medical Association ( T&TMA) , being one of the oldest and most vibrant in the region is singularly valued by the College. CCFP continues to hope that the T&TMA will establish and formalize and most importantly give its blessings to a Society or subgroup of GP/Family Medicine, within its ranks, that will then be able to take its proper place amongst the other Specialty Subgroups in Trinidad and Tobago. CCFP also hopes that the T&TMA will give full support to Conference Coordinator Dr. Rohan Maharaj and his team and their 5th Tri-Ennial Pan-Caribe Family Medicine Conference planned for October 2012 in Port of Spain, Trinidad.

37

Caribbean Medical Journal

Palliative Care Report on the First Palliative Care Conference in Trinidad and Tobago A. Nobee1 MBBS, V. Basdeo1MBBS, M. Rios1MD, S. Seemungal2LLb, R. Clerk2 MBBS, J. Sabga2MBBS, K. Cox-Seignoret2MRCGP, K.Capildeo1MD & T. Seemungal1 PhD 1 Department

of Clinical Medical Sciences, Faculty of Medical Sciences, The University of the West Indies, St Augustine Campus 2 The Palliative Care Society of Trinidad and Tobago, Port of Spain, Trinidad and Tobago.

ABSTRACT Background When the burdens of curative treatment outweigh the benefits, the goal of a patient's care may change from curing to comfort also called palliative care. It improves the quality of life of patients and families who face life-threatening illness, by providing pain and symptom relief, spiritual and psychosocial support from diagnosis to the end of life and bereavement. The essential components of palliative care are effective control of symptoms and effective communication with patients, their families, and others involved in their care. Rehabilitation, with the aim of maximizing independence, is also essential. As the disease progresses, continuity of care becomes increasingly important, coordination between services is required, and information must be transferred promptly and efficiently between professionals in the community, in hospitals, and in hospices.

Objectives This report seeks to highlight the beginnings of palliative care worldwide and in Trinidad and Tobago, how these services developed and what the citizens of Trinidad and Tobago have available at their disposal and lastly, a bit about how this field is projected to develop in the future.

Methodology For this report interviews were conducted with Dr. Richard Clerk and other members of the board of the Palliative Care Society of Trinidad and Tobago. Information was also collected at the palliative care society inaugural palliative care conference.

This conference ran from the 22nd to the 23rd October, 2011.

Major findings Palliative care services in Trinidad and Tobago include 3 major hospices in Port of Spain and St James, one other is being established at the Petrotrin Medical Centre located at Point a Pierre. There are also out-patient clinics in San Fernando, Princes Town, Couva and Siparia that cater to the needs of residents in the south of the island. Home based palliative care and oncology services are also provided in the St. Andrew/ St. David region by the East Regional Health Authority which is a community based nurse led service. In certain instances palliative care is provided by general practitioners who have had limited experiences in this field.

Conclusions The population of Trinidad and Tobago is aging, as such there is a greater demand for palliative care, however services in Trinidad and Tobago are far from adequate for our population however, great strides are being taken to resolve this deficit.

38

Palliative care services are projected to be in greater demand worldwide by 2020 due to rising mortality from noncommunicable diseases which are expected to cause nearly five times as many deaths as communicable diseases in low- and middle-income countries. Worldwide, the focus on palliative care has primarily been on cancer care, however if cardiovascular diseases continue to surpass cancer as the most common cause of death then more facilities will be required manage end stage cardiac disease. In this context the formation of the palliative care society is timely.

Key words: Palliative Care, non-communicable diseases, NCDs, cardiac disease, cancer, death rates in Trinidad and Tobago Introduction The World Health Organization defines palliative care as â&#x20AC;&#x153;the active total care of patients whose disease is not responsive to curative treatment. Control of pain, of other symptoms, and of psychological, social and spiritual problems, is paramount. The goal of palliative care is achievement of the best quality of life for patients and their families.â&#x20AC;? The palliative care movement in Trinidad and Tobago has come a long way since its inception and now many patients can benefit from these services. What started off as one small hospice with a few beds has now become a movement toward the greater awareness of the needs of the terminally ill. However the field of palliative care medicine still has a long way to go in achieving standards such as those in the United States or Canada, but through the work of those passionate about this slightly known field many steps are currently being commenced to achieve these goals.

The Palliative Care Society of Trinidad and Tobago was established in April 2011. Their goals were to transform the care available to terminally ill persons and their families through increased medical support, social support and advocacy; the Society is also dedicated to improving training and education about palliative care in Trinidad and Tobago. This society recently held its inaugural conference on palliative care in collaboration with the Temmy Latner Centre for Palliative Care at Mount Sinai Hospital and the Division of Palliative Care in the Department of Family and Community Medicine at the University of Toronto, Canada. It was a two day conference held on the 22nd to the 23rd October, 2011 at the Eric Williams Medical Sciences Complex, Mt. Hope. The intention here was primarily sensitization and education of health care providers and other care givers as to the importance of providing care to persons with end of life illnesses. The conference was attended by approximately 150 participants. Both days were comprised of presentations by various speakers all actively involved in palliative care from both Trinidad and abroad. Guest speakers

Caribbean Medical Journal REPORT ON THE FIRST PALLIATIVE CARE CONFERENCE IN TRINIDAD AND TOBAGO

from the Mount Sinai Hospital were Professor S.L Librach and Dr. Leah Steinberg. On the first day presentations were done on the need for palliative care, quality end of life care, Trinidadian as well as Canadian palliative care. Also addressed were the issues of working with patient families, cancer pain, communication issues as well as oncological palliative care.

Continued on the second day was another look at Trinidad’s palliative care services, management of symptoms, palliative radiotherapy and advanced care planning. Ethical issues in end of care life, grief management, challenges as well as ethical issues were all discussed. Workshops were also held on both days that addressed in detail the issues dealt with in the presentations as well as provided an opportunity to clarify any questions.

The importance of Palliative Care Why is palliative care so important that the palliative care society felt the growing need to raise awareness? Many individuals hold the belief that palliative care is synonymous with hospice care; however it is so much more. When the burdens of curative treatment outweigh the benefits, the goal of a patient's care may change from curing to comfort. As the patient nears the end of life, palliative care may extend to involve hospice care if the patient and his or her family wish. Palliative care neither hastens nor prolongs death, it integrates the psychological and spiritual aspects of care, it also offers support to families during the illness and in their bereavement.

The essential components of palliative care are effective control of symptoms and effective communication with patients, their families, and others involved in their care. Rehabilitation, with the aim of maximizing independence, is also essential. As the disease progresses, continuity of care becomes increasingly important, coordination between services is required, and information must be transferred promptly and efficiently between professionals in the community, in hospitals, and in hospices.

In Trinidad and Tobago hospice as well as non-hospice services are available to individuals with end of life issues. Non-hospice care is appropriate for anyone with a serious, complex illness, whether they are expected to recover fully, to live with chronic illness for an extended time, or to experience disease progression.

In contrast, although hospice care is also palliative, the term hospice applies to care administered in patients with a prognosis of 6 months or less to live History of Palliative Care in the Western World The term “hospice” can be traced back to medieval times when it referred to a place of shelter and rest for weary or ill travelers on a long journey. The original hospices, from the fourth to eleventh centuries, were houses of rest and shelter for pilgrims and crusaders; these hospices were usually kept by religious orders. The earliest hospitals and hospices were one entity, again based in the church. Now however hospices are facilities or programs designed to provide a caring environment for meeting the physical and emotional needs of the terminally ill. During the eighteenth and nineteenth centuries, religious orders established hospices to care for the dying in France, Ireland, and London. One of these was the St. Joseph’s Hospice for the Dying Poor, established by the Irish Sisters of Charity.

The modern hospice movement started in England in the 1960’s thanks to research at the said mentioned hospital by Dame Cicely Saunders. She was allowed to experiment by giving

regular dosages of drugs to four patients with terminal cancer.

Saunders, who died in 2005, was a nurse, a social worker, and a physician. Her work was observed with some skepticism at that time, which soon turned to interest as the results showed a marked improvement in the quality of these patients' lives.

By the time she left St Joseph's, she had observed and documented over 1,000 cases of cancer patients that provided the basis of this area of research. St. Christopher’s Hospice was thence founded by her in 1967 - in a residential suburb of London. Careful observations of the use and effects of morphine and similar drugs also originated at this hospice. Dame Cicely's pioneering work was soon followed by others including a Dr. Richard Lamberton.

In early 1983 he visited Trinidad delivering a seminar that addressed palliative care as a specialty as well as the inadequacy of the hospital system in their approach to end of life care at that time. Consequently on August 14th 1983 the Living Water Community established the Living Water Community Hospice.

At that time this was the only establishment of its kind in Trinidad.

Services available in Trinidad & Tobago For approximately 28 years the palliative care services have brought relief and comfort to an increasing number of people however services in Trinidad do not have an island wide reach as at present only three hospices are in operation at this time, the Living Water Community Hospice, the Vitas House Hospice and the Mercy Home Hospice. These are all free hospices for terminally ill patients, run by non-governmental organizations that provide palliative care to anyone in need. The Vitas House Hospice addresses the needs of terminally ill cancer patients while a wider range of terminal ailments are dealt with at the Living Water Community Hospice. The Mercy Home on the other hand, provides care to those living with HIV. Hospices alone are not the only palliative care service offered to the population. Home based palliative care and oncology services are also provided in the St. Andrew/ St. David region by the East Regional Health Authority which is a community based nurse led service. These provide the patient with the option to live their last days at home, provided adequate care can be provided. Services offered to the south of the island would include a palliative care clinic at San Fernando General Hospital as well as smaller clinics at the district health facilities of Princes town, Couva and Siparia. These are outpatient clinics and as such once these patients cannot be adequately managed at home then these patients are transferred to one of the three established hospices in Port of Spain and St. James if the patient and family wishes. There are no established hospices that cater to the needs of residents of south Trinidad but however one is being established at the Petrotrin Medical Centre located at Point a Pierre. In certain instances palliative care is provided by general practitioners who have had limited experiences in this field.

Discussion Death is a natural part of life; however the thought of dying to many individuals can be frightening. Many imagine it to be a painful and lonely experience. Palliative care seeks to allay these fears and as such every individual has the right to adequate, comfortable and dignified care at the end of life. According to the discussions at the palliative care conference it can be seen 39

Caribbean Medical Journal REPORT ON THE FIRST PALLIATIVE CARE CONFERENCE IN TRINIDAD AND TOBAGO

that the palliative care services in Trinidad and Tobago are far from adequate for our population as compared to developed nations such as Canada, however, great strides are being taken to resolve this deficit.

Palliative care services are projected to be in greater demand worldwide as according to the secretary general of the United Nations in the 2011 general assembly by 2020, noncommunicable diseases are projected to cause nearly five times as many deaths as communicable diseases worldwide in lowand middle-income countries (Table 1 and Graph 1) Commonly known as chronic or lifestyle-related diseases, the major noncommunicable diseases are cardiovascular diseases, diabetes, cancers and chronic respiratory diseases. The rapidly growing magnitude of such diseases is driven in part by population ageing, the negative impact of urbanization and the globalization of trade and marketing.

Appendix Table 1: Main predicted causes of death for 2020 and previous causes in 1990. (Based on Murray and Lopez (11).

Disorder Ischaemic heart disease

Predicted ranking in 2020 Previous ranking in 1990

1

1

continue to surpass cancer as the most common cause of death then more facilities need to be implemented to deal with these patients’ needs. If dying is the one thing that is common between us human beings why can’t more be done to make this process as comfortable as possible? Realistically all patients cannot be cured and as such it’s only fair that the best options are available to the rest.

The population of the population of Trinidad and Tobago is aging, and the odds of living a long life and dying during old age are far better than they were approximately 20 years ago (Table 2) The average life expectancy of both sexes is now 70 years old as reported by the World Health Organization mortality country fact sheet which means that our palliative care needs are growing as the population ages, these statistics represent a demographic shift and one for which this country is clearly unprepared. The emphasis here is mainly placed on cancer care, however according to the United Nations statistics division as of 2010, Trinidad and Tobago cancer deaths were 123 (per 100000 populations) as compared to cardiovascular diseases that were 364 (per 100000 populations).

Table 2 Showing life expectancy in Trinidad and Tobago Summary

Year Males

Females

Both sexes

Cerebrovascular diseases including stroke

2

2

Chronic Obstructive pulmonary disease (COPD)

3

6

Lower respiratory tract infections

4

3

Lung. Trachea and bronchial cancer

5

10

Graph 1 Deaths in low and middle income countries.

Source: WHO mortality country fact sheet In reference to the World Bank’s projections of socioeconomic development over the next quarter century, researchers at the World Health Organization set out to forecast global trends in death and disease. Among the catalog of predictions is that the current top two killers—heart disease and stroke—will hold on to their rankings. These diseases run a chronic course and as such the demise of these patients progress slower than that of other terminal illnesses, thus increasing these patient’s needs for palliative care. Worldwide the focus on palliative care has primarily been on cancer care, however if cardiovascular diseases 40

Population (millions)

2005

1

1

1

Life expectancy (years)

2004

67

73

70

Under-5 mortality (per 1000 live births)

2004

24

15

20

Adult mortality (per 1000)

2004

257

156

Maternal mortality (per 100000 live births) 2000

110

Source: World Health Statistics 2006

Source: WHO mortality country fact sheet Being aware of these trajectories may help clinicians plan care to meet their patient's multidimensional needs better, and help patients and carers cope with their situation. According to the statistics it can be seen that the palliative care needs of patients with other non-communicable diseases are not being addressed as adequately as they should and if the World Bank’s projections of socioeconomic development ring through then Trinidad and Tobago has a long way to go in fulfilling those needs and may even be heading in the wrong direction as to patients’ needs.

Palliative care can also be viewed as the flip side to the medical coin; those who cannot be cured are offered palliation so why then is this field so inadequately recognized. After all is said and done current trends predict that the need for palliative care in the next 20 years will only become greater so what then are our plans to address them?

Leading the way forward is the palliative care society as they have planned numerous activities to address the future palliative care issues, these include, ongoing palliative care training workshops for general practitioners and nurses and the public; supporting the UWI in training health care personnel in Palliative Care in association with the University of Toronto; forming family support groups and grief counseling workshops, they also hope to conduct research into and lobby for better integrated palliative care in Trinidad and Tobago. In addition the University of the West Indies has in the planning stage a MSc program in palliative care to specially train health care workers in this field which is common place in developed nations. In countries such

Caribbean Medical Journal REPORT ON THE FIRST PALLIATIVE CARE CONFERENCE IN TRINIDAD AND TOBAGO

as Canada or United States, most units now combine inpatient and home care services, and many independent home care teams also exist, working closely with general practitioners and other workers in primary care. In Trinidad however the emphasis is on inpatient care and isolation from mainstream care, however this country has only just begun home based care and as such is on its way to a more integrated approach on how we view palliative care.

While there are serious shortages of essential drugs for symptom control, political and cultural attitudes against the use of opioids and other drugs are major factors in poor control of symptoms worldwide. This highlights the need for national, economic, and political policies on cancer and palliative care. However in his opening address to the meeting, the Minister of Health, Dr. Fuad Khan, mentioned “Further, the Ministry of Health has developed a policy whereby the state will provide the appropriate protocols and resources for a pain management approach for terminally ill patients. You see, top quality palliative care and pain management are what will make the difference between a peaceful death and one that is fraught with prolonged suffering.”

The Minister also stated “In fact, I am pleased to tell you today that the Ministry provides millions of dollars in subventions annually to several non-governmental organizations to improve the quality of care given during this vulnerable time.” This is a positive sign for the palliative care providers of Trinidad and Tobago as these establishments are mainly run by contributions from well-wishers as well as fund raising activities, it also proves that palliative care is being recognized as a very important part of health care by more individuals even those in authority.

If these statements are indeed true then the palliative care needs of patients in Trinidad and Tobago are well on their way to being adequately addressed.

Finally we take this opportunity to remind us all that the relevance of palliative care will be judged not by the number of specialist teams or technology but by the capacity to influence the care offered to all patients irrespective of diagnosis and place of care. Human beings all have the right to being treated as

individuals, with dignity and respect during their lives and even at the end of it and this is the central goal of our Society. The next conference of The Society will be on 20th to 21st October 2012. It will be expected that at this conference we will obtain data on the health care burden of end stage diseases in Trinidad and Tobago.

Corresponding Author Professor Terence Seemungal, Professor of Medicine, Department of Clinical Medical Sciences, c/o The General Hospital, Charlotte Street Port of Spain Email: terence.seemungal@sta.uwi.edu REFERENCES 1. WHO/UNICEF estimates of disease incidence. Geneva, World Health Organization, 2009 (www.who.int/immunization_monitoring/data/en/).

2. “WHO Definition of Palliative Care”. World Health Organization. http://www.who.int/cancer/palliative/definition/en/ (accessed 15th october,2011).

3. O'Neill B., Fallon M. ABC of palliative care: Principles of palliative care and pain control. BMJ 2007; 315 : 801.

4. Radbrusch L., Downing J. “Principles Of Palliative Care” International association for the study of pain. h t t p : / / w w w. i a s p pain.org/AM/Template.cfm?Section=Home&Template=/CM/ContentDis play.cfm&ContentID=12167 accessed 15th October, 2011 5. The art of dying. Changing attitudes to a good death from antiquity to the p r e s e n t d a y. L o n d o n , K i n g s c o l l e g e , L o n d o n (www.kcl.ac/uk/depsta/humanities/art_of_dying) (Accessed October 2011) 6. International association for hospice and palliative care (www.hospicecare.com) (November 2011) 7. Murtagh FEM, Preston M,Higginson I. Patterns of dying: palliativecare for non-malignant disease. Clin Med 2004; 4:39–44 8. Macmillan Cancer Relief. Our principles of patient-centred care. London: M a c m i l l a n C a n c e r R e l i e f 2 0 0 4 . www.professionalresources.org.uk/Macmillan 9. Walsh D, Gombeski W, Goldstein P, Hayes D, Armour M. Managing a palliative oncology program: the role of a business plan. J Pain Symptom Manage 1994; 9 (2): 109–18. doi:10.1016/0885-3924(94)90163-5.

PMID 7517428.

10. Hill RR. Clinical pharmacy services in a home-based palliative care program.

Am J Health Syst Pharm 2007; 64 (8): 806, 808, 810. doi:10.2146/ajhp060124. PMID 17420193.

11. Murray CJ, Lopez AD. Alternative projections of mortality and disability by cause 1990-2020: Global Burden of Disease Study. Lancet 1997; 349(9064):1498-504.

41

Caribbean Medical Journal

Medical Philosophy The Good Samaritan Aneesha Gopaul MB BS, Diploma in Family Medicine.

Primary Care Physician, NCRHA. Scenario: I had just completed a sixteen hour shift at the emergency room and left the hospital to find some well deserved nourishment.

As I turned onto the highway, I could see a maddeningly, long line of traffic that had ground to a halt. There seemed to have been an accident further ahead. Without further thought, I jumped out of the car and raced toward the collision site. A thick crowd had gathered around, but no one approached the wrecked vehicle in which a man, bloody and supposedly unconscious, lay draped over the steering wheel amidst a million shards of glass.

Stethoscope in hand, I valiantly parted the crowd, which on recognition of my assumed profession, fell apart and allowed me through. A deafening silence fell over the crowd.

As I pulled the unfortunate driver off the steering wheel and back against the seat, the bravery and gusto that I had approached the situation with waned and my heart began to sink as the murmurs of the crowd began to intensify. I could tell that he was already deceased…….there was nothing that I could humanly do to breathe life into his still warm body. An impatient observer shouted from the crowd “Doc, save him, save him”. Yet another called out with the question that I feared to answer, “Doc is he alive or dead?”

•

With my every movement being intimately recorded by so many observers, I knew that now I could not simply just turn and walk away. I began to mentally berate myself for becoming involved in such a situation. In true altruistic fashion I had acted first and thought later. This crowd would not be satisfied unless I had performed some sort of medical procedure. So, I decided to go through the motions. Ignoring the constant battery and bombardment of questions, I palpated the neck for the carotid pulse. I listened for heart sounds and lung sounds. Then I took a deep breath and spun around to face the curious onlookers, determined not to utter a single implicating word.

It was at this point I was accosted by an ambulance personnel whom I had previous interaction with in the ER several times.

While I had chosen to ignore the crowd, he had stood behind me and observed and realized that the driver had died on impact.

The look on my face confirmed it and as I walked away, he declared that he was not carrying any deceased person in his ambulance to the hospital as it was a waste of his time. He then suggested that I sign his papers to prove this, so that he could leave the scene. The disgruntled crowd continued to make a din and several insisted that the doctor could have done something to save the driver.

The “Event-feature-emotion complex” by states that the processing of this moral information in a network of different neural modules (corticolimbic cerebral network) is necessary to moral judgements and moral acts [1].

THE SIGNIFICANT ELEMENTS OF THIS ETHICAL PROBLEM • Should a physician provide or withhold treatment from emergency victims/ patients outside of the hospital?

• What are the physician’s duties to these patients outside of the hospital?

• Is the physician authorized to provide care to these patients?

• What are the societal expectations of doctors in helping emergency victims?

42

• •

What are the legal implications of helping a patient outside of the hospital?

What are the ethical implications of the EHS personnel behavior in this scenario?

How does the community view death and dying? What are the social issues involved in the dying process?

ETHICAL DISCOURSE Every time a physician is faced with an ethical decision, the decision needs to be made between what is right and what is wrong. Several models have attempted to explain how one is able to arrive at such a decision.

The “Social Intuitionist” model refers to the idea that moral truths do exist but are not grasped by a conscious and rationalized process. According to this, moral truths come into our sphere of knowledge by a process more akin to perception. Thus moral intuitions come first and directly cause moral judgements [1].

In the “Normative” model, there is more emphasis on a cognitive approach. In essence, moral judgement is not only innate and intuitive but is also acquired and shaped through strong cultural rules that have no natural neural substrate [1].

The mechanisms of moral decision making outlined above greatly influence our moral emotions displayed in ethical situations. Physicians often encounter distressed individuals.

Many of us feel empathy and wish to assist in alleviating that distress. It is from these feelings and emotions that the “Good Samaritan” behavior is born.

Good Samaritan laws are acts protecting (from liability) those who choose to aid others who are injured or ill. They are intended to reduce bystanders’ hesitation to assist, for fear of being sued or prosecuted for unintentional injury or wrongful death. These laws vary from jurisdiction to jurisdiction and some extend protection to professional rescuers when they are acting in a volunteer capacity [2]. The Good Samaritan law has its roots in the parable told by Jesus in Luke 10:25-37. It recounts the aid given by traveler from Samaria to another traveler of a different religious and ethnic background who had been beaten and robbed by bandits. The High priest and the Levite had both chosen to ignore the wounded man and did not provide compassionate assistance.

In Levitism, a “good levite” would have displayed obeisance to the law and regulations by entering into a relationship of assisting the wounded. The nature of this relationship would have entailed an implicit or weakly explicit type of contract to provide help. In this instance, non-compliance or failure to stop and help the wounded man constitutes a “bad levite”. Similarly

Caribbean Medical Journal THE GOOD SAMARITAN

today, in some European countries (Germany) and Quebec, (Canada), the Civil law system mandates that there is a duty to rescue. One can be prosecuted and convicted in a court of law for failure to provide assistance.

The concept of Samaritanism goes beyond the rules of Levitism.

Samaritanism refers to attitudes taken when help is called for in situations devoid of any overt or covertly agreed obligation.

An act is Good Samaritanism when it gratuitously averts harm from the victim and it is bad Samaritanism if the individual being in a position, but not under the obligation to help, chooses not to do so [3].

In Trinidad and Tobago, there are no Civil laws that mandate physicians to stop and assist in roadside emergencies. We (physicians) are not legally bound by contractual obligations to provide medical assistance for any patient that we have not been previously responsible for. The common law has however been evolving with respect to the provision of emergency medical services. Using the principles of Negligence law which entertains the concepts of proximity and foreseeability, the law can establish that there is a relationship between the individual and the physician if the individual is sufficiently close to require a duty of care that can be provided by the said physician. This is well illustrated in the Australian case of Woods vs. Lowns.

The defendant physician refused a request to assist a person experiencing an epileptic seizure a short distance from his office.

The court concluded that the physician had a duty to provide emergency care because there was a relationship of sufficient proximity between the parties. Public policy was also found to support such a duty.

Common law can also create a nexus by using the principle of reliance to establish that the individual has relied upon the services offered by the physician. There are other situations in which the physician is bound to stop to help. These include if there is a pre-existing relationship between the patient and the physician as well as through public policy considerations and in certain jurisdictions, by legislation as mentioned previously.

From an ethical view point, if one considers professional standards and moral imperatives, it is clear that the physician has role to fulfill in society. The society has legitimate expectations that the physician will offer his services to prevent harm in many situations that have not been contractually formalized. The physician is therefore expected by society to act both altruistically and supererogatorily when dealing with victims in a roadside accident.

In retrospect, I was correct to willingly approach (showing altruism) the accident scene and to become involved in the situation (supererogation) rather than to remain unidentified and inside my vehicle. While I had approached to provide assistance willingly, I became hesitant when actually confronted with the reality because it was the first time I had been in a situation such as this. I also realized that I was ill prepared to provide assistance. Without the necessary basic equipment such as gloves, airways and intravenous lines, how could I provide the necessary help [4]? This was complicated by the fact that the situation had taken me out of my domain of comfort (emergency room).

A medical emergency outside the hospital or medical practice

setting can be one of the most unnerving situations that a physician encounters. Ample evidence exists that CPR performed early in the field greatly increases the victim’s chances of survival [4]. Would I have been willing to perform CPR on a bleeding victim with my hands unprotected from shards of glass? Would I have been willing to perform mouth to mouth resuscitation? What about the risk contracting an infectious disease? Without the right precautionary tools, I would have found it difficult to resuscitate the victim if he were alive.

Further to this, at the said time, I was not fully cognizant of the legal ramifications of stopping to assist in roadside accidents.

None the less, I had a duty to assist in the caring of any injured victims and to show unconditional positive regard for their lives and wellbeing. A duty of care was owed to the victim merely because I have had the opportunity of being highly trained and educated as a physician. The medical knowledge that I had garnered during years of training was not proprietary. In essence, I have been “hired” by society to cover medical services beyond the individual needs of the sick. Some of these services include preventive medicine, public health and spontaneous assistance in emergencies [3].

I was authorized to provide such care because of my role in society. It can also be argued that there was permission to provide care because it appeared that the patient was unconscious on approaching the vehicle. Therefore consent was implied rather than actively given. This could be construed as acting paternalistically to seek the best interests of the patient. The autonomy of the patient was compromised in this situation of life and death because he was not able to ask for help or participate in the medical decision making process concerning his own survival. My aim to save a life was beyond the borders of beneficence but non- malificence would have to be highly considered at the scene of this accident. With my fairly extensive training in emergency room medicine as well BLS and ACLS certification, I am sure that my medical assistance would “first do no harm”. This would have been the essence of a roadside consultation with this patient.

If the patient had been alive and my actions while providing medical assistance had resulted in death, disfigurement or disability, then as long as I had acted rationally, in good faith and in accordance with my level of training, I would have been protected under the Good Samaritan behavior code. This appears to be only loosely formulated as a concept rather than an actual law in Trinidad and Tobago. I would not have been found to be civilly liable for any damages incurred to the patient in the course of assisting, once my actions or omissions were not found to be reckless or grossly negligent or constituting wanton misconduct. If my actions were in keeping with what a reasonably skilled doctor would do (as evidenced by a responsible body of medical men/ expert witness), then any accusations from the crowd of onlookers or family members of the deceased could be dispelled. Knowing these moral, ethical and legal aspects of roadside assistance now better prepares me not only to be more confident and more willing to assist but to be better prepared to do so, should the occasion arise again.

The issue of the behavior of the EHS personnel in refusing to transfer the accident victim raises some ethical concerns. These individuals are supposed to perform basic emergency management and transfer the victims to the Emergency room 43

Caribbean Medical Journal THE GOOD SAMARITAN

via their specific protocols. These protocols do not involve the presence of a medical practitioner or by virtue, any assistance rendered at the scene of the accident. The doctor at the scene should be primarily an asset to the patient in order to help stabilize, treat injuries, and save lives. While this may assist the EHS in carrying out their duties to the victim, it should never extend outside of this realm to deal with death. The EHS service cannot legally, ethically or morally take that decision to refuse to transport a patient based on what the doctor says (patient is dead/alive) at the scene. The protocols of the EHS require these individuals to document the status of the patient on arrival at the hospital (dead on arrival/ alive with vital signs) before “hand over” to the ER physician.

The social issue of death and dying also needs to be considered.

The reaction of the crowd is not surprising since the acceptance of death is a highly charged emotional issue, even for those who are not acquainted with the individual whose life is at risk.

Several studies have shown that factors such as presence of pain, symptom management, preparation for death, a sense of completion, being mentally aware /clear decision making, not being a burden, having made funeral arrangements are considered by many to be important at the end of life [5]. Additionally each individual perception of quality of end of life and what constitutes a “good death” differs. The physician’s view of death tends to focus more on the biomedical aspects. Physicians rated a death as being of high quality if the individual had been treated according to professional and ethical standards. For the patient and family however, the psychosocial and spiritual issues are just as important as physiologic concerns [5].

While the crowd has expressed these concerns about the already deceased man, it has now become obvious that my reaction to the crowd was in keeping with how I had been trained to think as a professional. I was immersed in somehow trying to perform a medical miracle within ethical and professional standards that I failed to see him as a person. Some may argue that this is crucial to be able to perform medical management effectively in such a charged environment. However, if I had been more aware of the lay person’s criteria for a “good death” and their response to dying, I may have been more empathic and been able to communicate with the crowd and explain the situation to them.

REFERENCES 1. Tassy S, Le Coz P, Wicker B. Current knowledge in moral cognition can improve medical ethics. J Med Ethics 2008; 34: 679-682.

2. Good Samaritan Law. Wikipedia.org.

3. Kottow MH. Against the magnanimous in medical ethics. Journal of Medical Ethics 1990;16:124-128.

4. Whiticar RA, Potts DJ, Smith S, Thirumamanivannan G. Be prepared!

Drugs and equipment for 'Good Samaritan' acts. Eur J Emerg Med 2007;14(4):236-8.

5. Glannon W, Ross LJ. Are doctors altruistic? J Med Ethics 2002;28:68-69.

44

Caribbean Medical Journal

Medicolegal Ethics in the everyday Ethics in the everyday Think of ethics and you might think of life-changing decisions; blood transfusions for a Jehovah’s Witness patient, or end of life care. Think again, says Sarah Whitehouse, writer at the Medical Protection Society (MPS). Some of the most important ethical healthcare decisions are in the everyday.

Ethics is ever-present in healthcare decisions, even if it might not at first appear that way. “Medicolegal problems can often be like icebergs; ethics is the bit you can’t see,” says Dr Deborah Bowman, Senior Lecturer in Medical Ethics and Law at St George’s, University of London.1 The focus for ethical debate is often on classic dilemmas drawn from acute medicine in a secondary care setting. Yet there are many instances in both primary and secondary care where value choices are made every day, on a less dramatic scale. How long should you spend with each patient? What if one patient is clearly distressed, but you have a list of other patients to see and your surgery has overrun? Should you refer a patient for further investigation because they are anxious, despite your judgment telling you otherwise?

Defining the ordinary In February 2011, the Royal Society of Medicine (RSM) hosted a seminar, “Ethics of the Ordinary”, in association with the Royal College of General Practitioners (RCGP), looking at the moral and ethical implications of the day-to-day lives of patients and debating the best way to respond to these challenges.

The seminar drew out the conflict between the general and the particular; the general being medical knowledge, and the particular being the ethical way it is applied to each individual patient. Knowledge may be neutral, but how it is applied is not.

Dr Iona Heath, President of the RCGP, explains: “Medical science has achieved success through the application of general rules to individuals. Given the uniqueness of every individual, there will always be a mismatch between the general and the particular, which leads to the possibility of different courses of action, different views of what is right and wrong, and hence a situation where ethics is fundamental.”2 When does ethics come into play?

Ethics is invoked whenever a healthcare professional sees a patient. For the consultation to be ethical, the competent patient needs to be involved in the decision-making process. There may, however, be some circumstances where the patient cannot be involved, eg, very young children, unconscious patients, or patients with extreme cognitive problems.

Ethical dilemmas in primary care Primary care is often the first step in a patient journey, so small decisions (eg, when to refer) may make big differences later on.3 One of the most obvious ethical decisions in primary care is how much time to spend with each patient. Dr Zaid Al-Najjar, Medicolegal Adviser at MPS and a practising GP, asks: “Is it fair that you spend twice as long with Mrs Smith than you do with other patients to discuss her chronic problems each week,

when in comparison, Mrs Brown also needs 20 minutes to discuss three problems in a list? You tell Mrs Brown to rebook to discuss the third problem because there are 15 patients outside and you are running 30 minutes late, but spend the extra time with Mrs Smith as you know her well. GPs need to be really good with time management and need to know when to set boundaries with patients who are recurrent attendees, and when to spend that little bit more time with someone else.”

Patients may be frequent attenders or may visit the surgery after a long absence with a “shopping list” of medical complaints.

Sometimes, the most ethical thing to do is to ask patients with a long list to rebook, but other times it might be better to hear them out as there might be a chance they do not re-attend. This is where prioritisation and good judgment comes into play.

Some patients may demand a referral when they don’t strictly need it, and some GPs may acquiesce for fear of complaints, or as a result of practising defensively. Again, it is important to balance the general with the particular; the individual with the patient population as a whole.

Sharing resources Ethical decisions have to be made each time drugs or treatments are prescribed, all with differing costs. Such considerations are not just the doctor’s responsibility but those of the local commissioning body, pharmacy adviser and society in general.

When resources are stretched, how far should this affect a doctor’s decision to prescribe?

Dr Al-Najjar says: “NICE guidance offers advice regarding evidence-based medicine and cost-effectiveness, but these are just guidelines. Every patient needs assessing on an individual basis. Is it fair that Mr Jones, who you started on medication that costs $50 per prescription, is being treated for the same condition as Mr White, who has been prescribed the latest fashionable blood pressure medication costing $200 per prescription by his cardiologist and is happy but oblivious to the cost implications?”

Doctors have to treat all patients ethically and fairly. The ethical duty to avoid discriminating against a patient due to age is clear.

Increasingly, doctors have to deal with language barriers and patients’ experiences of healthcare in other countries. Dr AlNajjar explains: “My experience is that in an increasingly multicultural population, a significant number of patients from abroad with different healthcare systems and expectations expect more invasive, quicker medicine. Demands for specialist referral are higher as many countries have little faith in GPs and have direct access to specialists. Managing patients’ expectations and what can be realistically provided by a publically funded health service is one of the most challenging aspects of general practice.

Everyday ethics in secondary care There are many similarities in primary and secondary care when it comes to ethics; confidentiality and consent being the cornerstones of good medical care. Both areas have to contend with making everyday ethical decisions regarding the allocation of resources. However, in secondary care, often more complex

45

Caribbean Medical Journal ETHICS IN THE EVERYDAY

ethical decisions can arise, such as who should take priority for ICU treatment, or receive an organ donation?

What happens when healthcare professionals see a patient regularly is completely different to when a patient is seen for the first time in the Emergency Department (ED). In emergency care, or in care involving locum GPs or unscheduled care providers, ethical dilemmas have been termed “a slice of time”.4 Here, doctors and patients are strangers who will rarely meet again once treatment has been completed.

Conversely, GPs treat patients over a longer period of time.5 As a result, GPs have to look at the longer-term effects of their course of action and the ethical decisions they take. They might be more involved in encouraging patients to adopt healthier lifestyles, eg, weight management or smoking cessation advice, as they are aware of the bigger picture. GPs might have to give constructive and honest advice about the potential consequences of non-compliance. More directly, Dr Bowman asks: “Does familiarity breed consent?”5 The GMC stresses that informed consent applies to all doctors, regardless of their specialty: “You must work in partnership with your patients. You should discuss with them their condition and treatment options in a way they can understand, and respect their right to make decisions about their care.”6 It has been argued that hospital doctors may encourage the ethical concept of patient autonomy in its purest form, in that they do not have to deal with the consequences of patient noncompliance with treatment.7 Patients continue to present to their GP for further review, with the full complexity of their problems.

Healing beyond the patient Do you have an ethical duty to treat society beyond the realm of the individual patient? The GMC suggests responsibility for the health of the population: “You should encourage patients and the public to take an interest in their health and to take action to improve and maintain it. This may include advising patients on the effects of their life choices on their health and well-being and the possible outcomes of their treatment.”8 For example, smoking cessation initiatives would be very relevant in a deprived area with a high smoking prevalence among the population. “Doctors have a wider responsibility to society. Many GPs see themselves as the gatekeepers of the

46

healthcare system and ensuring that healthcare is fairly distributed,” Dr Al-Najjar adds. Alongside this, however, GPs often regard themselves as the patient’s advocate, championing what is right for their particular circumstances. In this way, we return to the needs of the general and the particular, and the important ethical balancing act that informs the two.

Conclusion Considering the ethics of the everyday is an important guard against the increasing professionalisation and isolation of ethics from every clinical encounter. Dr Bowman states: “Moral choices are made every day by every one of us; ethics is not something that should be rarefied.”

The ordinary is extraordinary in ethics – consent, patient autonomy and the application of general medical knowledge to the individual patient all come into play within the most seemingly innocuous of doctor–patient consultations, whether in primary or secondary care.

•

The new MPS Guide to Medical Ethics – A Map for the Moral Maze is an invaluable reference point for the increasingly complex ethical dilemmas doctors face.

Members can view this on the MPS website at w w w. m e d i c a l p r o t e c t i o n . o r g / u k / a d v i c e - a n d publications/booklets

The original article can be found in MPS’s September 2011 edition of Casebook at www.medicalprotection.org/uk/casebook-september-2011 REFERENCES 1 Bowman, D, “An Ethicist’s View” delivered at the RSM’s Ethics of the Ordinary seminar (15.2.11) http://www.rsmvideos.com/ 2 Heath, I, “A View From the Consulting Room” delivered at the RSM’s Ethics of the Ordinary seminar, (15.2.11) http://www.rsmvideos.com/ 3 Papanikitas A, Toon P, Primary Care Ethics: a Body of Literature and a Community of Scholars? J R Soc Med 1-3 pp1-3 (2011) 4 Doyal L, Doyal L, Sokol, D, General Practitioners Face Ethico-legal Problems too! Postgrad Med J vol 85 no 1006 pp393-394 (2009) 5 Ibid 1 6 GMC, Consent: Patients and doctors making decisions together p5 (2008) 7 Doyal L, Ethico-legal Dilemmas within General Practice, p50, in Dowrick C and Frith L, General Practice and Ethics: Uncertainty and responsibility, Routledge (1999) 8 GMC, Good Medical Practice p9 (2006)

Caribbean Medical Journal

History A brief history of Chest Medicine & Surgery in Trinidad & Tobago (This presentation was given by Mr. Ferdinand Penco FRCS, Thoracic Surgeon, at the launching of the Thoracic Society of Trinidad & Tobago (TSOTT) on 27th June, 2012) It is my privilege this evening to relate to you in brief, the beginning and the history of the development of Chest Medicine & Surgery in Trinidad and Tobago.

I shall attempt to do so by a series of moving tableaux and vignettes of the major players. Remembering that the beginnings and early history is really the tale of Pulmonary Tuberculosis.

The story opens with the freeing of the African Slaves from the estates by the Abolition Act of 1833. Imagine the situation, they are suddenly all on their own, they must find employment, housing and build their own communities. They flee to the towns, Port-of-Spain where they house themselves in hovels, tenement buildings and backyards. These are poorly ventilated, badly lit, congested, whole families confined to 10’ x 12’ rooms, unhygienic.

They find employment as housemaids, cooks, grooms, butlers, laundresses and ironers. Bush Medicine, Cough Medicines like Palatol, Scott’s emulsion, Creosote Paragoric, fish oils and Zeba Pique are their nostrums, and it goes without saying that avoidance of fresh air (draughts) and superstition are the order of the day. There is no history of the Native Caribs having Tuberculosis, nor the enslaved Africans. Tuberculosis is a European Disease; it is introduced here by the seamen and the soldiers in the garrisons. The emancipated slaves in their newfound freedom move freely among these Europeans. The Tubercle Bacterium finding fertile soil runs riot, the death rate is up to 70%, headed only by Malaria as a cause of death, in the colony.

It is the turn of the century; enter the towering figure of George Henry Masson. He is a national, he has trained in medicine in the United Kingdom, and he has studied under Dr. Sir Robert Phillip, a renowned specialist in the research of Tuberculosis.

In Edinburgh during this period of training, he witnessed the opening of the first Tuberculosis Dispensary in the UK. Dr Masson was also trained and understood the value of quarantine and isolation. He returns to Trinidad in 1901. He is accompanied by his wife Jessie, a Scot, who is a trained nurse.

Among his seminal achievements there were the following: 1. He was instrumental in the formation of the Association for the Prevention and Treatment of Tuberculosis on February 22nd 1905.

2. This was followed in August of the same year by the establishment of a Dispensary to treat Tuberculosis. It was situated at # 48 Frederick St, opposite Woodford Square (Then known as Brunswick Square) near Prince Street.

Its mandate was the following a) The dissemination of information as to the prevention and treatment of Consumption or Tuberculosis Pulmonary

Tuberculosis was commonly referred to as “consumption” at that time. b) The maintenance of an institution in Port-of Spain for the gratuitous treatment of and the giving of advice to sufferers from pulmonary tuberculosis. c) The essential establishment of a Sanatorium for the cure of Consumption.

Dr Masson was our representative to an International Conference on Tuberculosis held in Rome, the year was 1912. At this time the Trinidad Association for the Prevention of Tuberculosis was known as the leading body in the West Indies for the control and treatment of Tuberculosis. Again, largely as a result of his efforts, in March 1913 an Inter-colonial Conference for the Prevention and Treatment of Tuberculosis was held at what was then known as The Royal Victoria Institute at the corner of Frederick & Keate Streets. This is now known as the National Museum. During that conference the Association acquired a yard at 66-68 Prince Street which was used as an exhibition, not only to show how yards should be ideally constructed but also that there was a correlation between badly constructed barrack yard housing and Tuberculosis. There were two resolutions arising from that conference: 1. That Tuberculosis Associations should be established in The Colonies wherever they do not now exist and 2. That another Inter Colonial Conference should be held in some other Colony in 1915.

But now the first of the two Great World Wars has started and so everything, exclusive to the War Efforts took second place.

That is not to say that the work of the Association came to a stop, it continued to educate, interview and isolate cases wherever possible. The indomitable, indefatigable light that was George Henry Masson was snuffed on Dec 30th 1940. His thesis on small pox earned him the D.S.c, and he was recognized internationally for his pioneering work in Tuberculosis. Here in the Caribbean he was recognized by the Colonial Government for the Quarantine Convention out of which a common quarantine policy was adopted for the West Indies.

We now move to a more recent era.

The 2nd Great War has ended but the scourge of Tuberculosis is wreaking havoc, not only in Europe but also in the West Indies. During World War 11 the Lend Lease programme was instituted. U.S. Forces arrive in Trinidad. They set up air bases in Carlsen Field, in Longdenville, Waller Field, in Cumuto, with a Naval Base at Chaguaramas. They thus bring employment with higher salaries especially for agricultural workers, but they also bring what used to be called Venereal Diseases, now more accurately termed Sexually Transmitted Diseases. When the war ends, they vacate some of their buildings or camps. The one at Camp Ogden is to become the Masson Hospital, while the Caribbean Medical Centre on Wrightson Road is to become

47

Caribbean Medical Journal A BRIEF HISTORY OF CHEST MEDICINE & SURGERY IN TRINIDAD & TOBAGO

a Chest Clinic and a centre for the diagnosis treatment, and contact tracing not only of Venereal Diseases but also for Tuberculosis. The tradition of excellent record keeping, as established by the Association is thus maintained.

During and between the Great Wars special Wards at the Colonial Hospitals for the isolation of Tuberculosis cases were eventually established. The one at Port-of- Spain was called the “Pavilion”.

The man who looked after the patients at the Pavilion was Dr. Victor Donawa. He could be described as an eccentric, lonely, brooding figure but much loved by his patients and by the nurses who worked with him. My memory of him was that of a grey, gentleman, did not speak very much but well versed in the management of Tuberculosis. He died at Caura in the sixties of intractable congestive cardiac failure. But I go astray….. Again!

World War 11 has ended, Tuberculosis is making havoc not only in the colonies but worldwide. The British Colonial Government decides to set up Tuberculosis programmes in its colonies. In Trinidad, Dr. William Joseph Branday is recruited from Jamaica in 1946. At the time of his recruitment he is the Medical Officer in charge of the Slipe Pen Road T.B. Hospital in Jamaica. He is appointed the Chief Tuberculosis Officer as he has had specialist training in Tuberculosis. He brings with him Miss Laurel Rowe who will become one of the heroines in this drama. (She is with us today) On his arrival inTrinidad, what does he find?

He finds the “Pavilion” at the Port-of-Spain Colonial Hospital, a unit of maybe 12 beds, there is also a six bed area in the infectious disease ward in San Fernando. The Pavilion in POS is managed by Dr. Victor Donawa. Branday sets about the enormous task placed before him. He recognizes the potential of the Caribbean Medical Centre at Wrightson Road. It has Laboratory and X-Ray capabilities so he converts it into a Chest Clinic where large and miniature X-Rays can be carried out as well as sputum samples examined for the Tubercule Bacillus; both by microscopy and culture. Dr Branday also recognizes the inadequacies of the units at the POS Colonial Hospital and at the San F’do Colonial Hospital. His only ally now is the brooding Dr. Victor Donawa. He teams up with the then Director of Medical Services, Dr. E.J Sankarali, they journey to San F’do to persuade the young Dr. Kenneth Reginald Richardson who has had training in Pulmonary Tuberculosis in the UK to cooperate with Dr.Branday and to organize a Chest Clinic in San Fernando which Dr.Richardson would run. Dr Richardson agrees, and these two (2) clinics are soon overrun with patients afflicted with Tuberculosis.

The long overdue erection of a sanatorium in some lofty mountainside blessed with fresh unpolluted air has finally begun at Caura. Its foundation stone is laid by Sir Bede Clifford, Governor of the Island in 1945. Progress on its construction is slow and the dynamic Dr. Branday needs a hospital to isolate and treat Tuberculosis patients now!! He has started improved treatment of the patients at the clinics and wards at POS and San F’do. These consisted of the various forms of Collapse Therapy e.g. Artificial Pneumothorax, Pneumoperitoneum , Phrenic Nerve Crush, Plombage Thoracoplasties and Apicolysis.

A short explanation is required here; the various forms of collapse therapy were designed to rest the upper zones of the lungs which were the areas with the highest levels of O2 which is what the Tubercle Bacillus require to thrive on. By collapsing 48

(resting) those areas the O2 saturation fell and the Tubercle Bacillus was disadvantaged. At that time also, medications inimical to the Tubercle Bacillus appeared on the scene, they were the antibiotic Streptomycin, this had to be injected together with the chemotherapeutic agents PAS (Para-Amino Salycic Acid) and later INAH (Isonazid) this last one still irreplaceable up to the present.

But let us pick up the Narrative again; Dr. Branday needs a Hospital site dedicated to the isolation and cure of Tuberculosis.

He finds the abandoned U.S. Army Building Camp Ogden on Long Circular Road and persuades the Authorities to open a facility there as construction of the Caura Sanatorium is only half completed. His persuasion works and by August 1948 the camp is converted into a Hospital of eight wards with 240 beds.

It is called the Masson Hospital after the late, great Henry Joseph Masson and Dr. Victor Donawa is to be in charge. I sense something peculiar here because at this critical time Dr. Donawa proceeds on Long Leave to England and Dr. R.K.Richardson is put in charge of the Masson Hospital. Dr. Donawa returns in mid 1949 to take charge and Dr. Richardson therefore returns to his post at San F’do Colonial Hospital. So now there is a well organized structure for managing Pulmonary Tuberculosis, it is called the Tuberculosis Division later to evolve into the Thoracic Division.

In 1949 Dr. Richardson proceeds on leave to study Tuberculosis and Chest Diseases at the Brompton Chest Hospital in London, The Broomfield Sanatorium in Essex and the National Miniature Radiology Centre in London. He further obtains the MRCP examination in 1950 and went on to the Pasteur Institute in Paris and the State Serum Institute Copenhagen Denmark to study the production and use of the vaccine B.C.G While this is going on the Caura Sanatorium is finally completed and commissioned on July 3rd 1950. It is a 194 bed hospital; with amongst other things a well designed operating theatre, a laboratory, a pharmacy and an X-Ray department. We have in our presence here today, Mr. Raymond Williams, who was one of the first employees at its opening. He continued to work there as an X-Ray technician until his retirement in Dec 1988.

He can give a more interesting history about Caura than I can ever give but at the end of it TSOTT would be inundated with law suits.

So the Caura Sanatorium shining new is opened and the Masson Hospital which has already been in operation for 18 months continues to function alongside Caura until the Masson is finally closed in 1961. Its patients are transferred to two new wings added to the Caura Sanatorium and Mrs. Mc Dowell nee Rowe who was at the Masson Hospital is transferred to Caura as a junior Matron.

Now let us pause to recap & review the status quo – • The year is 1950; the Tuberculosis Division has been established with the Jamaican Dr. William Joseph Branday at its helm as Chief Tuberculosis Officer.

• This division is made up of two Chest Clinics, one at Wrightson Road in POS, the other on the grounds of the San F’do Hospital • There are now two hospitals dedicated to the treatment of Pulmonary Tuberculosis – • The Masson Hospital at the site of Camp Ogden medically

Caribbean Medical Journal A BRIEF HISTORY OF CHEST MEDICINE & SURGERY IN TRINIDAD & TOBAGO

• •

managed by the brooding Dr. Victor Donawa and the administration of nursing by the vivacious, attractive and eager to work Miss Laurel Rowe.

• The Masson Hospital houses the severely afflicted cases of Pulmonary Tuberculosis, where most of the patients die, (one of them the young wife of Raymond Williams).

• The shinning new sparkling Caura Sanatorium with its panoramic view of the Caroni plains, and its pure unsullied air, Dr. William Joseph Branday, skilled and dedicated, takes a delight in its beautiful gardens and surroundings, makes certain that not only the patients are scrupulously and well looked after, but that the grounds are maintained in pristine condition.

Dr AA Peat, another Jamaican is the Director of Medical Services of the Colony.

Dr. Richardson is in Europe completing his studies.

Dr. Branday together with Dr. Peat encourages Sir Henry Pierre to join the fight against Pulmonary Tuberculosis. He is the leading surgeon in Trinidad; he is to surgery what Sir Garfield Sobers is to Cricket, he is the supreme craftsman. He travels to London where he is well known and is introduced to Thoracic Surgery. After a short exposure to the craft there, he returns to Trinidad and assisted by Dr Branday they carry out the first Thoracic Surgical Operation in Trinidad; it is successful, however, Sir Henry, not withstanding his superb technical skill, has not anticipated the other requirements for successful lung surgery.

He treats it as he is accustomed He is a general surgeon, his skills are in demand all over the island, and post operative care, blood loss and case selection are not ideal – the mortality rate is forbiddingly high.

Dr. R.K. Richardson re-enters the fray in 1951, fresh from his training in Europe. He is appalled by the surgical mortality rate.

He resolves to address it, and in the fifties goes again to the U.K and trains in Thoracic Surgery under a Thoracic Surgeon – Professor A.L. d’ Abreu in Birmingham But I have been remiss; I have not referred to the Heroines or Leading Ladies in this saga. At the opening of the Caura Sanatorium, the leading lady was an English Woman Miss Jill Moore, her supporting cast were Miss Violet Huggins, later Mrs. Violet Lines, Miss Lillian Chung, and many others including later on Mrs. Laurel Rowe, who had served at Masson Hospital..

I can see them now, in their sparkling white uniforms and gleaming starched veils. They look the part.

We now approach my own era in Chest Medicine which began in 1961-62. Usher in Dr. Leonard Egbert Dasent, it is the mid 1950’s, he has qualified in Dublin, he loves Chest medicine and so joins the team. He is tall and commanding, demands respect and gets it. The patients call him ‘Castro” after Fidel Castro, not only because of his appearance, but because like Fidel, he rules the wards under his care with a firm unrelenting hand.

But he loves his nurses and his patients and has a droll sense of humor. He works with the Division until his retirement in

the eighties. His contribution to the development of Chest Medicine is inestimable. He died on January 31st 1998, unsung – his only official recognition is an obituary written by the late Aubrey Adams in the Sunday Guardian. His wife and family are with us tonight.

There was also Dr. Dan, recruited in the fifties, by the Colonial Office, he took over the administration of the Southern Chest Clinic and was the Thoracic Medical Director during the 70’s and 80’s. He is swift, efficient and pragmatic, but without passion. But again I wander and meander.

Dr Branday completed his tour of duty in Trinidad in early 1960’s; he died in his homeland of Port Maria, Jamaica in 1976 at the age of 75. By the time of his departure, he had overseen the control and decimation of Tuberculosis in the island. His contribution was never given the recognition and accolades that he deserved, but such is life! I regret I did not obtain a photograph of him.

Dr Richardson took over as Chief Tuberculosis Officer on the resignation of Dr. Branday. He continued as Chief Surgeon and physician at the facility until his resignation around 1970. Too much cannot be said about his dedication and contribution during his tenure. Dr. Richardson died on October 27th 2008.

I remember him as a dynamic, forceful man, who was eager to achieve.

I have tried to record a brief history of the development of Chest Medicine & Surgery. The history is not exhaustive; the detailed history is soon to be the subject of a book compiled by the Chest and Heart Association, the draft of which I was allowed to draw freely from. I hope you have found this presentation entertaining and informative. I commend you for your attention throughout.

But before I go, I would like to acknowledge the following persons who assisted me in the gathering of information for this presentation: • The Chest and Heart Association – with a special mention to Ms. Mary T. Alexander.

• The descendants of Dr. Joseph Henry Masson, his grandson Alexander David Masson is here tonight, • Mrs. May Dasent, widow of Dr Leonard Dasent, she is here.

• Mrs. Laurel Mc Dowell, the last of our leading ladies left standing.

• Mr. Raymond Williams for being here tonight, • Mrs. Jennifer De lima, step daughter of Sir Henry Pierre and • Last but by no means least my wife who kept me sane and controlled by advising me to calm down ‘Ferdie” calm down.

Thank you and have a Good Night.

49

Caribbean Medical Journal

Icons of Medicine AJF ‘Fred’ PencoPioneer of Thoracic Surgery in Trinidad & Tobago Ian R. Ramnarine FRCS Thoracic Surgeon, EWMSC, Mt. Hope.

Introduction Albert Joseph Ferdinand Penco is a truly great man who humbly and quietly continues to lead the National Thoracic Surgical Services without recognition for the many accomplishments and achievements made during his watch.

Early days Fred’ was born and raised near Longdenville Chaguanas. The name ‘Fred’ is derived from his middle name which was shortened to ‘Ferdi’, then to ‘Fred.’ He stayed at a boarding house in Cascade while he went to secondary school at Fatima and St Mary’s. Sports were not his ‘thing’, but as a schoolboy he was one of the founding members of the Silver Stars Steel Orchestra. Not only did he play second pan with them during his time at school, but he was also in their ‘Stage Side’ as well.

While the whole panside played on the road for Carnival, the smaller core of the Stage Side played at parties, functions and competitions. He continued playing with Silver Stars until 1955 when he left for University. There is a well documented episode in the book ‘A Graphic History of Pan’ where, as a school boy, during pan practice, the police arrested the group when the neighbours’ complained about the noise. They spent the night in jail and later challenged the case against them. They each won $250 for wrongful arrest. A princely some in those days.

In interviewing him, I realised that I should have chosen somewhere more secluded because we were interrupted by a constant stream of admirers, all eager to shake his hand and offer some praise or thanks. This he soaked up graciously, and always with a modest compliment in return, almost embarrassed from the attention.

University College Dublin Following College, his parents took him straight off to University College Dublin to Medical School. The Urologist Dr Andrew Yip Hoi (deceased) and Dr James Chin Yuen Kee were classmates. Prof Courtney Bartholomew, Macdonald ‘Mack’ Jorsling and Ivan Perot were also friends at the same school, but ahead of him. Fred’ was now a member of a steel pan band with Vitalis Gomes, Andrew Marcellin and Courtney Prevatt with Gene Rodriguez as the ‘Crooner.’ They played gigs and Bartholomew was able to get some better paying ones through his contacts. This provided a tidy source of income because by time he graduated he was already married and a father.

Return to Trinidad Internship was completed in Dublin before he returned to Trinidad in 1962. He was promptly posted to the Caura Sanitorium as a ‘Tuberculosis Officer’. Soon came the recognition that, not only were Tuberculosis patients being treated at the Sanitorium, but also patients with lung cancer, asthma and other cardiopulmonary diseases. The name was changed to the Caura Chest Hospital and the facilities expanded. Fred now worked with a team that included Dr RK Richardson, Dr Dasent and Dr Dan. 50

AJF Penco when working as a Tuberculosis Officer at Caura Sanitorium Chest surgery at Caura had previously been performed by Sir Henry Pierre and Mr Halsey McShine who came from the Portof-Spain Hospital to operate. Dr RK Richardson (father of Andrew) had his MRCP and, although he was a physician, performed most of the chest procedures with Fred as assistant.

Five years was spent at Caura, living with his young family in a house close to the entrance gate. He had initially wanted to be a physician, probably a cardiologist. However, as the treatment of Tuberculosis continued to improve, Richardson felt that Caura would develop into a Cardio-Pulmonary Hospital. It was Richardson who insisted that he pursue a career in Surgery. He packed up with his family and returned with them to Dublin in late 1967. He attended the Primary Fellowship Course at Hill Place in Edinburgh. He did several clinical attachments while studying and passed the Primary Fellowship of the Royal College of Surgeons in Edinburgh in the spring of 1968. Surgical clinical requirements had to be me because he had previously only worked in Thoracic Medicine and Surgery. These were met between the Dublin and Edinburgh Hospitals before achieving the FRCS from the Royal College of Surgeons in Edinburgh in 1970.

Thoracic Surgery Training Cardiothoracic Surgical training was at The Mater and The Royal Infirmary both in Dublin and later at the Edinburgh Royal Infirmary. Although he obtained mainly experience with Thoracic Surgical Procedures (such as lung resections, oesophageal surgery, pectus repairs), there was also extensive exposure to closed-heart and open heart procedures: valvotomies, coronary bypasses and valve replacements.

AJF Penco worked extensively with The Rotary Club and Heartbeat International for Cardiac Pacemaker Implantation since the late 1970s and that still continues.

Caribbean Medical Journal AJF ‘FRED’ PENCOPIONEER OF THORACIC SURGERY IN TRINIDAD & TOBAGO

In 1972 Fred returned to Trinidad and to Caura Hospital, now as the Senior Medical Officer and main surgeon. He returned on his own as his family elected to remain in Ireland. RK Richardson had now retired and Halsey McShine would come each operating day to assist him with thoracic procedures.

Several cardiothoracic surgeons have returned to Trinidad over the years, but he has outlasted them. These include Ormond Mendes (now in Melbourne Florida), Ken Sylvester (retired) and Stacy Brann (Philadelphia). He did spend six months training in cardiac surgery in 1972 at the St Michaels Hospital, Toronto.

But it was not until the Government sent a team to Houston to DeBakey’s unit in 1980, was there a serious push to develop the Cardiac Surgery Programme. Prof Bartholomew also played a role with this. The team comprised Fred, Bruce McIntosh (Anaesthetist), Rasheed Rahaman (Cardiologist), Selwyn Keller (Perfusionist) and one nurse each for the operating theatre and the intensive care unit.

The Caura Experience and Pioneering Surgery It has always been a great sense of disappointment for Fred that he did not receive the support necessary to develop the cardiac surgical programme at Caura. There was further training that was undertaken locally. The Artero-Venous Fistulas that were done for renal failure patients (initially requested by Dr John Hays in the late 1970s) were initially partially done for training to perform vascular anastomoses. A lot of the cardiovascular instruments in use today in the Thoracic Surgical Department were also bought at this time for the programme. However, Fred lists one of the best healthcare advances that he has seen locally is the provision of Cardiac Surgical Services for the general public.

without surgery. His success speaks volumes about his skills as a Thoracic Surgeon, attention to detail and commitment to the patient. Young surgeons would do well to adopt these qualities.

Fred also introduced Cardiac Pacemakers to Trinidad. The initial Cardiac Pacemakers were epicardially placed via a thoracotomy directly on the heart. HeartBeat International were and continue to be instrumental in the supply of the transvenous pacemakers that he has been implanting for thirty years!

Thoracic Surgical procedures are Fred’s forte. This includes surgery of the lung, pleura, chest wall, mediastinum, airway and oesophagus. Surgical colleagues also refer him the retrosternal goitres. His advice is often sought by Junior and Senior colleagues alike about a wide variety of surgical matters from procedural to personal. He was one of the first instructors for the ATLS (Advanced Trauma Life Support) Course when it began in Trinidad & Tobago. He continues to keep abreast of modern surgical techniques and has continuosly modified his techniques for the benefit of his patients. When asked advice for Junior surgical trainees, he insists that they pay special attention to detail when operating on a patient for the first time because this is the best time to obtain the best results. Successive operations are more difficult for both surgeon and patient. He adds: ‘So take your time and be meticulous!’ Always impeccably dressed and moving with a sense of purpose, Fred always seems to have a moment for any of his numerous admirers. He has been with his current wife Fazia since the late 1980s.

Fred started work at Caura the same year as our Independence and he continues to put his much junior colleagues to shame with the incredible workload that he maintains. His appointment as a ‘Tuberculosis Officer’ at Caura Sanitorium in 1962 also pre-dates formal Thoracic Surgical Services in Trinidad & Tobago. However, it is mainly for his modesty and personality that he is best known and these place him head and shoulders above his peers. He holds these qualities dear and searches for them in others. He is also famous for his charm and charisma that one would do well to emulate. It is incredible that one so humble could have provided sterling service, within the public service for such a long time without the recognition that he deserves.

AJF Penco at his office in Caura Hospital.

Despite the failure to develop the cardiac surgical programme and the lack of supporting staff and intensive care facilities, Fred has managed to perform a number of closed Mitral Valvotomies and other closed heart procedures . Dr Rasheed Rahaman still sees in his cardiac clinic a patient who was pregnant when she had her valvotomy performed by Fred in the 1970s. The child from that pregnancy still accompanies her.

A number of procedures for congenital cardiac defects have also been successfully performed. These include Patent Ductus Arteriosus (PDA) Ligation, Blalock-Taussig (BT) Shunts and Repair of Aortic Coarctation.

The signifance of the successful performance of these very high risk procedures in this setting has been severely unerestimated, especially where adequately trained staff and specialist equipment are not available. These patients would have certainly died

AJF Penco heading to work today Always impeccably dressed.

It is a mark of the greatness of the man that he wants to know what all the fuss is about….he is just being himself.

51

Caribbean Medical Journal

From the Archives Dr. Premchand Ratan Dr. Premchand Ratan is one the most respected Physicians in Trinidad & Tobago and has impacted on the lives of many graduates of the University of the West Indies.. He was in the Second Medical Class at the University College of the West Indies, Jamaica in 1949 and has seen the practice of Medicine evolve over the past 50 years. His address to the graduating Class of 2005 was one of the most memorable and outstanding at the Faculty of Medical Sciences. We include the speech in its entirety.

ADDRESS TO UWI MEDICAL AND DENTAL GRADUATES AT OATH TAKING CEREMONY ON 15 JUNE 2005 Chairman, distinguished guests, ladies and gentlemen, graduates in Medicine and Dentistry. I feel honoured to be asked to give the feature address to graduates of my own University, and I do so with pleasure, especially as I have participated in the training of some of those who have taken the Oath today. I congratulate all of you who have graduated and all those who have won prizes. I entered University College of the West Indies in September 1949. You can imagine the joy, the exhilaration of being in your twenties at a new university. This combination produced a fizz of excitement which remained with me throughout my student days. I trust that you too have enjoyed being a student and that you have had your share of fizz and excitement. Now that your desire to become a doctor as soon as possible has been fulfilled, your desire should now be, to be as perfectly qualified as possible to do the work of a doctor.Let me remind you that the work of a doctor carries with it the burden of responsibility.

All of you, I am sure, entered medicine as bright, idealistic people with highly positive attitudes. I trust that your exposure to role models and to professionalism would have contributed to helping you remain that way. You in your turn, as you go along and become senior, have a responsibility of shaping the doctors of tomorrow, and must therefore seek to influence your juniors- doctors and medical students- in a positive way, by yourselves being role models. Every doctor is given the opportunity of being a teacher whether it is of his juniors, medical students, or nurses, and so it is worth remembering that “our teachings reflect our attitudes, prejudices, honesty and humility. It is our example that will be remembered long after the differential diagnoses are forgotten” Some of you from early in your training would have decided what you eventually want to do. But those of you who have not yet decided don’t have to be disturbed. Somewhere along the way “by accident, or swayed by motives of idealism, religion, ambition, materialism” you will choose your career. No doubt too, an important factor influencing you will be the dynamism and inspirational leadership of members of the profession. If your teachers have not inspired and motivated you then an important part of your medical education can be considered missing. For the women graduates the choice of career can be even more difficult than for men, as they sometimes have to choose between having a successful career and a family life in 52

which they find personal happiness and satisfaction.

Whatever career you choose and in whatever way you practise, you will contribute to the debate between those who like Bernard Shaw see the profession as a conspiracy against society and those who like Robert Louis Stevenson see doctors as the flowers of all mankind. Your aim should be to conduct yourselves in such a way as to earn the high esteem and trust of the public.

In some ways medicine may be fundamentally different from other professions but we all know that doctors have the same failings as the rest of humanity. It was Bernard Shaw’s view that “ as to the honour and conscience of doctors, they have as much as any other class of men, no more and no less” There are issues that will cause you unease from time to time-financial insecurity; the encroachment on leisure time and family time; poor working conditions, inadequate remuneration, poor accommodation, long inhumane hours, fear of litigation, overall disappointment in the ethical aspects of the practice of medicine; fear of the responsibilities in matters of life and death.

You may well at some time be asking yourself “Was medicine the right thing for me?”

But take heart. Lord Lister in his address to graduates in 1876 said, “If we have nothing but pecuniary rewards and worldly honours to look to, our profession would not be one to be desired. But in its practice you will find it attended with peculiar privileges second to none in intense interest and pure pleasures” Someone else has put it another way “My time out has convinced me that for all its pressures, all its intrusions into one’s family, all its demands on time and peace of mind there must be little to equal the privilege of receiving the trust and confidence of fellow humans.”

In my nearly 50 years of practising Medicine , I can tell you that medicine is fascinating, challenging and satisfying. Each patient is different; each encounter with a patient, even the same patient is different. Each encounter has so much humanity. Each day is a new learning experience and there is no room for being bored. There are a variety of emotions that confront you and you learn how to deal with them. But you are human, and you too will experience emotions that you will learn to control.

There is laughter and there are tears. If you eschew pomposity and arrogance the encounter can be mutually beneficial.

Lord Horder in one of his addresses said that the privilege of being exhortative is one of the few compensations allowed to those of us who have arrived at that stage in their professional lives when they are invited to give addresses like these. And so I give you a few of my exhortations.

Caribbean Medical Journal DR. PREMCHAND RATAN

Learning You must go on learning all your lives. A healthy sense of ignorance is a saving grace. No one can in 5 or 50 years learn all that one could wish about disease and its prevention and treatment. You have to keep on learning but you also have to learn to discard. Much of the knowledge acquired by doctors is deemed redundant a few years after they qualify. In learning medicine the task is never completed. You travel but never arrive. “Arrival is boring as is perfection. It is the journey that counts. I hope your road is a long one, full of adventure, full of discovery” Continuous learning is a necessity to ensure that your competence does not fall away. “The standard of Doctoring is the thing that matters and no one can maintain that except the doctor himself.”

In this connection this is what Sir Douglas Black had to say: “ The most unethical thing a practising doctor can do is to let his competence fall away. In other aspects of his practice he will sooner or later be pulled up by the law or by the judgement of his peers, but his ability to practise competently is primarily a burden on his conscience” Humility However learned and competent you may think you are, you must be humble. Don’t be afraid to say to yourself and to others “I don’t know”, and by the same token don’t be reluctant to seek help in furthering the patient’s interest. A doctor makes a hundred decisions a day; some are wrong some are right. You alternate forever between the ecstasy of a correct diagnosis and the crushing humiliation of a diagnostic blunder. But as Osler said: “Errors in judgement must occur in the practice of an art which consists largely in balancing probabilities” and because doctors deal with life and death and cannot avoid errors of judgement, they have to learn to live with their consciences.

Humility will make that lesson easier to learn.

“A willingness to change or question an established diagnosis made by yourself or others is an invaluable attitude for a doctor to possess. Nobody can be expected to recognize every diagnosis every time, but it is vital to be able to recognize when we might be mistaken or in doubt”. Don’t play God. If you do, you run the risk of being crucified!

The art of Medicine In this age of science and technology and rapid access to limitless information I exhort you to pay attention to the art of medicine.

Be sensitive to the needs of your patients. Culture and sensitivity should not be confined to the bacteriology laboratory. Industry can never be a substitute for sensitivity.

The motto of the Royal College of General Practitioners is “Cum scientia caritas”. It promotes the value of a scientific approach but it also proclaims the importance of compassion and thus the art of medicine. When you are sick you want the science to get you better but you want some one to hold your hand “Be alert to your patients’ emotional needs and demonstrate an empathic attitude toward them, if the contact is to be therapeutic. Empathy is not compassion, not sympathy, and certainly not pity. It has been defined as an insightful, subjective, non critical awareness of the feelings and emotions going on inside another person”

In “Cancer Ward” ,Alexander Solzhenitsyn writes “How many adult human beings are there now, at this minute, rushing about in mute panic wishing they could find a doctor, the kind of person to whom they can pour out the fears they have deeply concealed.” The drama of the operating theatre and the intensive care unit; the miracle of cardiac resuscitation; the control of status epilepticus; the restoration of normal breathing to an asthmatic and all the other life saving manoeuvres are what stand out in your memory. But “It is not only the doctors who perform hazardous operations or give life saving drugs who hold the scales at times between life and death. To sit quietly in a consulting room and talk to someone would not appear to the general public as a heroic or dramatic thing to do. There are many ways of saving lives. This is one of them” “If a physician possesses gentleness of manners and a compassionate heart and what Shakespeare called the milk of human kindness, the patient feels his approach like that of a guardian angel administering to his relief, while every visit of a physician who is unfeeling and rough in his manners, makes his heart sink as at the presence of one who comes to pronounce his doom.”

Communication Talk to your patients. Anxiety and fear are the inevitable consequences of poor communication between doctors and patients. Communicate with them about their disease, their fears, their wishes, their expectations and their hopes. Answer any questions they might have. But it will warm their hearts if you show an interest in what is going on in their lives.

There is a recurrent public disenchantment with doctors’ interpersonal skills, particularly in giving information and explanation, and so we must not be surprised at the rising popularity of alternative medicine, whose practitioners spend time with their patients. Doctors will have to learn especially in these days of rising litigation that a satisfied patient is as important as a medically improved one.

In closing let me leave you with two quotations.

The first is from Sir Robert Hutchinson From inability to leave well alone From too much zeal for what is new And contempt for what is old; From putting knowledge before wisdom Science before art, cleverness before commonsense; From treating patients as cases; and From making the cure of disease more grievous than its endurance Good Lord deliver us.

The other is from Osler, the quintessential physician “You are in this profession as a calling which exacts from you at every turn self sacrifice, devotion, love and tenderness to your fellow men. Once you get down to a purely business level, your influence is gone and the true light of your life is dimmed.

You must work in the missionary spirit, with a breath of charity that raises you far above the petty jealousies of life.” He went on to quote his hero Sir Thomas Browne: “No one should approach the temple of science with the soul of a money changer” My very best wishes for success and happiness as you serve the people of our nation.

53

Caribbean Medical Journal

Postgraduate Training DM Otorhinolaryngology (ORL) Introducion Since the implementation of restrictions on Postgraduate training posts to non-Europeans in the United Kingdom, the University of the West Indies has been on a drive to increase the number of Postgraduate Programmes offered by the Institution . The latest DM which has passed the rigorous approvals of the University in St. Augustine, is the programme in Otorhinolaryngology (ENT Surgery). The development of this Programme was achieved with involvement and support of the Trinidad & Tobago Society of Otolaryngologists and Head & Neck Surgeons (TTSOHNS) who identified that in the not too distant future, there was likely to be a shortage of Otorhinolaryngologists in the country. Minister Fazal Karim, the Permanent Secretary and the staff at the Ministry of Science, Technology and Tertiary Education (STTE) were also essential in achieving funding for the Programme.

Outline This Programme is due to start on 1 September , 2012 and candidates are scheduled to be taken in the three major hospitals – Eric Williams Medical Sciences Complex, San Fernando General Hospital and Port-of-Spain General Hospital.

Course of Study The Programme consists of two parts – Part 1 which normally will run for two years and Part 2 which normally will run for four years.

Part 1 1. The Part 1 of the Programme normally occupies 2 years.

2. During the Part 1 of the Programme: a. The trainees will rotate through two six month rotations in ORL and b. Four three month rotations which may include the following : General Surgery, Cardiothoracic Surgery, Neurosurgery, Plastic Surgery , Critical Care medicine, Emergency Medicine and Oral-Maxillofacial Surgery or any other rotation approved by the Programme Director.

Each trainee will be assessed at the end of each rotation.

2. The Part 1 examination is taken at the end two years in the basic sciences such Anatomy, Physiology, Pathology and Principles of Surgery, provided there have been satisfactory in-course assessments.

54

Part 2 1. The Part 2 of the Programme normally occupies 4 years.

During this period, trainees are assigned to ORL rotations with increasing levels of responsibility.

2. During the Programme the trainees will rotate through the three Major Hospitals – Eric Williams Medical Sciences Complex, Port of Spain General Hospital and San Fernando General Hospital or at approved institutions in the Region.

3. An Elective period in ORL of a total of one year must be spent at Institutions in or out of the Caribbean provided prior approval is obtained from the Specialty Board in Surgery. Such approval must be obtained at least six months prior to the commencement of the Elective period.

4. Institutions may be recognized for part or all of the training programme. The Specialty Board in Surgery will keep a list of approved institutions and appointments for the guidance of candidates. This list will be updated from time to time as necessary.

5. At least nine (9) months before the final Part II examination the trainee must submit a) a research project report; and b) a case book of ten (10) cases with commentaries.

Both of these must be accepted by the Board of Examiners before the trainee is eligible to do the Part II Examination.

6. Trainees must have reached a satisfactory standard during the in-course assessments before being allowed to enter for the Part II examination.

7. Before being admitted to the Part II examination, all trainees must submit a tabulation of all procedures performed by them and certified by their supervisor during the period of training.

Details of the Programme can be obtained from the Programme Director (Solaiman Juman FRCS – sollyjuman@gmail.com), Chairman of the Specialty Board or School of Graduate Studies and Research.

Caribbean Medical Journal

Elective Report Internal Medicine Elective at Eric Williams Medical Sciences Complex, Trinidad

By Sanita Belgrave and Khatija Mangera Elective Medical Students, UWI Cave Hill, Barbados This essay seeks to highlight our experiences at the Eric Williams Medical Sciences Complex in the Department of Internal Medicine. During our elective of four weeks, there was much to be learned and this knowledge is merely a drop in the ocean that flows. It felt like an intense programme geared towards teaching, experiencing and critical thinking. The first day began with the words of Professor Teelucksingh quite distinctly, “Who has a story?” A story was the history, examination findings and proposed management of a patient. As we listened, he interrupted intermittently to pose a question or highlighted an essential point. From this we learned that knowing the causes of each sign and symptom is essential as the sum of all these can be processed and narrowed to form a differential diagnosis, much like processing hamburgers to produce the final product.

However, while knowing is important, so is doing, and hence being able to elicit signs and observe the clues that the patient has are vital. By expanding knowledge, one can then actively seek signs that the patient may have: “You find what you look for”. The mandate of Internal Medicine aimed at promoting health and best practices. For instance, patients with diabetes mellitus were investigated for the metabolic syndrome and examination included fundoscopy and podiatry. This demonstrated that in eliciting a history and examination, one should emphasize the microvascular and macrovascular complications of the disease. Here, the importance of research in medical practice was also depicted, for example, “Does tight glycemic control prevent and delay the development of macrovascular complications to the same extent as microvascular complications?” The experience also showed that medicine is quite dynamic and that today’s findings may be obsolete in a few years time, as persons constantly develop hypotheses and investigate them.

sessions we understood that voluntary donations are the first line of defense in preventing the transmission of blood borne infections. We can now appreciate that with voluntary donations, people are not driven to withhold valuable information about their lifestyles because of the pressure of having to “save” the life of a loved one.

Of interest in endocrine clinic was the story of a middle aged Indo-Trinidadian female who was known to have hypothyroidism.

Clinically, she seemed to be experiencing symptoms of hypothyroidism, which to the inexperienced mind would prompt a change in medication. On further questioning, we discovered that she had cyclic oedema superimposed on a euthyroid state.

This session showed that the patient’s history provides much data that can generate the diagnosis. Thus, being able to extract this data requires knowing what questions to ask and hence, knowing the pathology. On this elective, opportunities were also afforded to sharpen knowledge basis in radiology, haematology, pulmonology, neurology and cardiology. In radiology, we were exposed to normal and abnormal chest radiographs and CT scans. The most intriguing was our session on CT scans of the brain, where we systematically examined the brain parenchyma, cisterns, ventricles and bone. We were then able to identify different types of intracranial haemorrhage.

The patient had a history of partial thyroidectomy due to hyperthyroidism. She presented with left eye proptosis, swelling of left parotid gland, multinodular goiter with tracheal deviation to the left, lipomata, warts on lower and upper limbs, an abdominal mass and osteoarthritis in both knees. CT scan revealed: left sphenoid wing meningioma, left parotid arteriovenous malformation, splenic hamartomas, pancreatic and pulmonary cysts, and uterine leiomyomata. The patient complained of dysphagia, diplopia on downward gaze, post menopausal bleeding and decreased mobility. Importantly, the patient was socially isolated and in poverty; this case thus showed the importance of a doctor’s role in finding the necessary social care for persons who don’t know how to.

The haematology experience included topics such as multiple myeloma, haematological malignancies, anaemia and complications of blood transfusions. One take-home message was “why are voluntary blood donations the best?” From the

During our time, there was much to see, smell, hear and touch.

In cardiology, we heard the murmurs of mitral, tricuspid and aortic regurgitation and mitral and pulmonary stenosis. We were also guided through normal and abnormal transthoracic echocardiograms. We observed the signs of uraemia, palpated a kidney transplant and felt the thrill of an arterio-venous fistula.

It was also an experience to visit the renal dialysis ward and listen to a few stories. What was striking was the increasing number of young diabetic patients who required dialysis due to poor glycemic control.

A few interesting patients included a twenty-nine year old AfroTrinidadian male known to have myasthenia gravis who presented in respiratory distress. Initially this was attributed to his underlying condition. However, he was then discovered to have a thymoma invading his left phrenic nerve contributing to his distress. The second case of note was a middle aged AfroTrinidadian female who presented to neurology with proptosis of the right eye following trauma to that eye. The patient was experiencing pain and on examination had impaired adduction, abduction and impaired downward and inward gaze, thus indicative of cranial nerves three, four and six palsies. The tentative diagnosis at the end of the session was carotid cavernous fistula. Perhaps the most intriguing patient was the middle aged Afro- Trinidadian female diagnosed with Cowden’s syndrome.

The Internal Medicine elective in Trinidad was truly an intellectual delight and it was a privilege to learn under Professor Teelucksingh. Other facilitators worth mentioning but not limited to include Dr. S. Khan, Dr. R. Ramlal, Dr. A. Sinanan, Dr. A. Baptiste, Dr. B. Bird, Dr. K. Capildeo, Dr. K. Charles, Dr. A. Esack, Dr.S. Jaggernauth, Dr. S. Sakhamuri, and Dr. C. Gomez-Akan. We are also grateful to the Ophthalmology team who showed us hospitality.

55

Caribbean Medical Journal

T&TMA Inauguration Dinner 2012 The Trinidad & Tobago Medical Association held its gala Inauguration Dinner on Saturday 28th January 2012 at Crowne Plaza Hotel. It was a packed audience which saw Dr. Maria Dillon Remy hand over the Presidency to Dr. Dev Ramoutar. The Minister of Health was represented by Dr. Akenath Misir, acting CMO. The Honourable Winston Dookeran , the Minister of Finance, and Mrs Dookeran were also in attendance as well as former First Lady, Mrs. Zalyhar Hassanali and Senator Dr. Victor Wheeler and Mrs. Wheeler.

One of the highlights of the night was the awarding the T&TMA’s most prestigious award, the Gold Pin, to former President Dr. Solaiman Juman .

Enclosed are excerpts of the addresses by Dr. Misir, Dr. Dillon-Remy and Dr. Ramoutar.

Dr. Akenath Misir, acting CMO “I am honoured this evening to have the privilege of bringing greetings to all of you distinguished colleagues, on behalf of the Honourable Minister of Health, Dr. Fuad Khan and the Ministry of Health.

I extend congratulations to Dr. Maria Dillon-Remy on successfully completing her term as President of the Medical Association of Trinidad and Tobago. Dr. Dillon-Remy, we wish you all the best in your future endeavours. Warm congratulations are also extended to incoming President, Dr. Dev Ramoutar on taking up the responsibility to lead this most distinguished body of professionals. Dr. Ramoutar, the Ministry of Health looks forward to working with the T&TMA over the course of the next year and we trust that it will continue to be a valuable stakeholder to the Ministry of Health, as we work together to ensure the availability and accessibility of high quality health care to the people of Trinidad and Tobago.

The Honourable Minister of Health has declared the year 2012 as the Year of Customer in the public health sector. As you are aware, the public health system does not enjoy the best reputation for customer service. We would like that to change. Our aim is to revolutionise customer service in the health sector so that each client/patient experiences the magic of service at every touch in the system from security, to administration to technical and clinical staff.

We would be providing customer service training as necessary to the different categories of staff, through the Regional Health Authorities and we shall be giving patients the opportunity to provide feedback on their hospital experience with the introduction of HCAHPS; the Hospital Consumer Assessment of Healthcare Providers and Systems survey- this is a globally standardized, publicly reported survey of a patient’s perspective of hospital care. This feedback will be used to identify weak areas in our service delivery that need to be strengthened and improved.

56

Some of our other plans for 2012, as we work to bring fist class health care to the people of Trinidad and Tobago include: • The establishment of a Health Accreditation Council to certify medical best practices and improve accountability and quality of health care in both the private and public sector.

• The establishment of a Health Intelligence System in the Ministry of Health as a repository for data and information across the health sector.

• The implementation of programmes to strengthen the Drug Inventory Management System.

• Introduction of specialized wards at our hospital for Chronic Non-communicable diseases.

• Development of mini-hospitals that contain x-ray lab facilities, pharmaceutical facilities and small operating theatres with same day surgery centers in communities.

• As part of our thrust to improve on our service delivery, we have plans to implement extended opening hours during the week as well as on weekends at some health facilities.

Funding will be allocated, and all levels of staff will be duly compensated for overtime hours.

In terms of legislation, our focus over the next year include the • Regional health Authority Amendment Bill • Bill of Patients and Obligations • Mental Health Bill • National accreditation Council Bill • National blood Transfusion Bill • The nurse and Midwives Amendment Bill • Emergency Ambulance Service and Emergency Personnel Bill • And we will be seeking to fully implement the Tobacco Control Act. With respect to human resources, we are also looking at a three year strategic plan to strategic plan to strengthen the capacity of the workforce and address staff shortages and of course, upgrades to infrastructure continue.

Colleagues, as I close, I again thank you on behalf of the Minister of Health, for your support over the last year and look forward to working with you this coming year to bring high quality health care to the people of Trinidad and Tobago.

I thank you.”

Caribbean Medical Journal T&TMA INAUGURATION DINNER 2012

Dr. Maria Dillon- Remy – Outgoing T&TMA President “ The honourable Mr. Winston Dookeran, Minister of Finance, Senator Dr. Victor Wheeler & Mrs. Wheeler; Dr. Surujpaul Telucksingh, president of the Medical board of Trinidad and Tobago and Mrs. Telucksingh, Mrs. Zalaya Hassanali – Patron of the TTMA, Incoming president of the TTMA, Dr. Dev Ramoutar and other members of council of TTMA, President of Medical Professional Association of Trinidad and Tobago – Dr. Shehenaz Mohammed; Medical Chief Of Staff Port of-Spain General Hospital – Dr. Colin Furlonge; Justice Alice York-Soo-Hon; Honouree – Dr. Solaiman Juman, other guests, friends, members of the media, it gives me pleasure to report to the body on our term of office for the year 2011. Few would have known the trepidation I felt when I stood in front of you in Tobago in January 2011. How was I going to deal with all these male members of council? How was I going to deal with the stresses of travel between Trinidad and Tobago? However I made it thanks to Almighty God who has blessed me with health and strength, my family and friends for the encouragement and support given to me over the period, thanks also to all the branch executives for your hard work. I am going to take the privilege of singling out Dr. Stacey Chamely who worked tirelessly as Secretary and was instrumental in coordinating the activities of the CME programs.

It was difficult, but she persisted and did an excellent job.

So what did we accomplish, this year?

MOST SIGNIFICANT: In Uruguay in October 2011, we became the 100th member of the World Medical Association (WMA). Dr. Solaiman Juman represented the organization and received our instruments.

What does this mean for us?

The WMA is an organization promoting the highest possible standards of medical ethics, and provides ethical guidance to physicians through its Declarations, Resolutions and Statements.

It also helps to guide National Medical Associations, governments and international organizations throughout the world. The Declarations, Resolutions and Statements cover a wide range of subjects, including an International Code of Medical Ethics, the rights of patients, research on human subjects, care of the sick and wounded in times of armed conflict, torture of prisoners, the use and abuse of drugs, family planning and pollution. The WMA is in official relations with the World Health Organization (WHO).

We have joined that august body and special thanks go out to Dr. Juman for his efforts in seeing this to fruition. We have also successfully bid to host the Commonwealth Medical Association’s meeting in Trinidad in 2013. This is the second time the CMA would be holding their meeting in the Caribbean. The efforts of becoming a member of WMA and CMA would assist in exposing our medical practitioners to our colleagues in different countries and we would use the opportunity ensure that the association positively impacts our health care delivery. In December 2011, Dr. Stacey Chamely ably represented us at the CMA conference

in Kenya did a presentation on Chronic Non-Communicable Diseases. At the invitation of the Jamaica Medical Association, in June, 2011, I attended their conference, and annual awards dinner. We have started discussions on further collaboration of our local associations, with the desire of forming a Caribbean Medical Association. In November, our executive had a planning meeting which would form the basis of a strategic plan for the organization for the next three years. Dr. Ramoutar has agreed to continue with this process.

COLLABORATIONS WITH THE MINISTRY OF HEALTH As with previous councils, we held meetings with the Minister of Health. In February our executive met with Minister Therese Baptiste – Cornelis and in September we met with Minister Dr. Fuad Khan. What has come out of those meetings? In May 2011, the ministry selected me to be a part of the Maternity Services Review committee, chaired by Dr. Lackhan Bodoe. The terms of reference of this committee includes among others: • To assess the main causes and trends in maternal and perinatal deaths, including identification of any avoidable or substandard factors • To recommend measures to improve clinical care and service provision with the goal of reducing maternal and perinatal mortality rates; That committee will be having it’s inaugural meeting on February 7th, 2012 and we hope to contribute to the workings of this committee, since the reduction of maternal mortality is of clearly a desirable goal of the TTMA. CONTINUING MEDICAL EDUCATION (CME) This has remained the bedrock of our focus as in other years and we have expanded our reach. Building on the experience gained over the years with administering CME’S, the Council presented a proposal to the Medical Board for the administration of CME’S for Medical Professionals on behalf of the Medical Board. They have agreed in principle and we are awaiting the signing of documents for same. This would change the face of the operations of the association We continued monthly CME’S in all branches and the topics covered were wide and varying. We had our quarterly CME’S with Johns Hopkins International and this year, four hundred and thirty one health care professionals attended three cardiology meetings. We also carried out 4 major meetings for the Medical Protection Society.

Our annual research conference was held in June and this year, in addition to our own cadre of local professionals, we included presenters from USA, Grenada, in addition to faculty from John’s Hopkins University.

First Oncology conference This year, we held our first Oncology conference in collaboration with the Mayo Clinic, University of the West Indies and the Southern Medical Clinic. It was well attended by one hundred and doctors and nurses. The topics included: • Treatment Challenges in the Management of the Cervical Cancer in T&T • Radiation for salvage of locally recurrent prostate cancer • Prostate cancer in T&T • Treatment of Acute Leukemia in the elderly patients • Blood transfusions in the cancer patient • Current management of ovarian cancer

57

Caribbean Medical Journal T&TMA INAUGURATION DINNER 2012

Caribbean Medical Journal – CMJ Our Caribbean Medical Journal took on a new look in 2011. It is more attractive and the funding mechanism is now allowing the magazine to pay for itself. All the reviews so far are positive.

Volunteerism: We continued to give back to the society and this year the South branch had an outreach held at Vessigny School. Two hundred and thirty six clients were seen and eleven doctors were in attendance. They collaborated with the Lions Club, Rotarty Club and Soroptimist clubs of San F'do on this project.

In Tobago, we continued the work done over the carnival Monday and Tuesday jointly with the Tobago Emergency Management Agency (TEMA) in assisting in supplying medical practitioners for the advanced medical post. We expanded our efforts with schools in Tobago by examining athletes from two schools instead of one. The children who needed further evaluation were referred.

BUILDING BRIDGES • With other Professionals: This year, we involved many more nurses in the CME’S. The Society of Radiographers listed our conference on their website and many of them came to the research conference.

• With young doctors Our efforts to mentor young doctors did not get off the ground as expected. However discussions started and we have planned

a meeting for the first quarter of this year, in conjunction with the UWI medical school.

• Between Trinidad and Tobago This year, we had our first TTMA family day at Pigeon point in Tobago. It was a resounding success. We were graced by the presence of the Secretary of Health Mrs. Claudia GroomeDuke. Dr. Ramoutar and Dr. Ramlackansingh, how could I forget the expressions of joy on your faces as you came to have the council meeting at Pigeon Point before the family day? Council has now put it on the annual agenda of the association. I thank Dr. Nathaniel Duke – the Tobago branch chairman for his effort in making it a success.

MEMBERSHIP DRIVE We maintained our level of paid up membership – the effort to increase members was not successful. A more concerted effort needs to be made in 2012. In summary, we collectively had a very busy and satisfying year. For me it was very rewarding and so I say to the team thanks very much for your support during this time. To the membership thanks for the opportunity afforded me to serve at a leadership level…and now, I pass the baton into the capable hands of Dr. Dev Ramoutar. Dev, as outgoing president, I remain committed to serving in whatever way I can to make your term a success. To members of the profession, please continue to support the efforts to build our glorious profession. Thank you and God bless the members of our profession.”

Dr. Dev Ramoutar – Incoming President " It is indeed an honor privilege and a challenge to accept Chain of Office of The President of the Trinidad and Tobago Medical Association. TTMA was formerly an arm of the British Medical Association, about thirty eight years ago by an Act of Parliament, TTMA became an autonomous entity. One of the cardinal functions of our organization is to maintain the honor and protect the interest of the medical fraternity. Our organization has a wide variety of skilled human resources, a fact which contribute to a legacy of excellence and success. I plan to pursue that course of excellence.

The agenda for the year 2012 consists of the following: CME- Continuing Medical Education. The new Medical Board Act makes it mandatory for licensed physicians to attain a required amount of CME-Credits to retain their license to practice medicine in Trinidad and Tobago. To this end, each of the four regionsTobago ,TTMA North, TTMA Central and TTMA South chaired respectfully by Dr. Nathaniel Duke, Dr. Muhammed Rahaman, Dr. Arnaz Maccum and Dr. Lainna Conyette will each host twelve monthly clinical meetings. Plus each region will also host an outreach program in a selected community. The programme will provide the opportunity to tract existing medical conditions and unearth medical problems which will require specialist medical care. These will be referred to specialist clinics in the public health sector.

58

Most importantly, they will also host an MPS meeting to highlight, sensitize and educate practitioners on how to avoid legal pitfalls in their practice. John Hopkins has over the past few years provided excellent teaching conferences. Unfortunately, their contract with the Trinidad and Tobago Government has expired and to date a new contract has not been approved. Our Research Conference will be hosted by TTMA midyear. I wish to thank Dr. Lester Goetez for embracing the challenge of coordinating this conference for yet another year. TTMA has been approachedbased on our success in hosting conferences- to coordinate and manage a Diabetic Conference for the Trinidad and Tobago Diabetic Association and an Oncology Conference for the Southern Medical Specialist Clinic and Mayo Clinic. So far we have fifty nine scheduled medical meetings.

C.M.F- Continuing Medical Fitness.

With the rise of sedimentary driven diseases, Dr. Frank Ramlackansingh has volunteered to: 1. Coordinate and manage the Annual TTMA Chancellor Hill hike.

2. To help recruit and encourage TTMA members to participate in the Annual Hike to El Tuche, which will take place on the first Sunday in May in 2012.

3. To arrange a Family Day that will incorporate physical activity.

4. Dr. Frank Ramlackansingh will be the PRO for TTMA and will ventilate in his usual inimitable style on matters pertaining to health issues.

HOUSE COMMITTEE Dr. Boysie Mahabir will be the House Committee Chairman. He will ensure the integrity of the Medical House and work closely

Caribbean Medical Journal T&TMA INAUGURATION DINNER 2012

with the office personnel to provide an efficient for TTMA. Due to the experience of Mala Persad, the diligence of Alicia Ramlackhansingh and the professionalism and meticulousness of Christine Rogers, his job will be challenging but not difficult.

CME COMMITTEE Dr. Stacey Chamley is the Chairperson for yet another year. She is energetic and very exacting in her endeavors. She will ensure that participants at clinical meetings complete their documentation of attendance and participation thereby ensuring that they get thei CME Credit from the American Academy for Continuing of Medical Edcuation.

STATEGIC PLAN COMMITTEE Our outgoing President, Dr. Maria Dillon-Remy, will be the Chairperson of the Strategic Planning Committee. This committee is mandated to formulate a Strategic Plan to chart the course of TTMA for the ensuing five years."

“Ladies and Gentlemen, The Nassau Declaration on the 6th July 2001 recognizes that “The Health of the region is the wealth of the region.” It was decided that a Regional Strategic Plan for the prevention and control of Chronic Non Communicable Diseases be developed and submitted for approval by March 2002. This was followed by the Port-of-Spain Declaration on 15th November 2007 at the Crowne Plaza; the message was “Uniting to stop the Epidemic of Chronic Diseases.” It was envisaged that by 2012, this year, 80% of people with Chronic Non Communicable Diseases would receive quality care and have access to preventative education based on regional guidelines. At a conference held at the Crowne Plaza on Saturday 20th September 2007, Professor Telucksingh remarked – and I quote “If we look at the leading cause of death in our country- heart disease, diabetes, cancer and cerebrovascular disease are the leaders. If you look at the top four diseases, they can also be linked to one underlying cause, and that is OBESITY.” In January 2011- The Diabetic Research and Prevention Institute-investigated 67,000 school children and came to the conclusion that 20% were overweight or obese and a high percentage had diabetes.

In September 20th 2011, in an address to the United Nation’s General Assembly given by the Prime Minister of Trinidad and Tobago, she suggested the Assembly strive to reduce Chronic Non Communicable Diseases by 25% by 2025.”

In November 2011, The Minister of Health launched the “Wellness Revolution” at the Hyatt Hotel with the theme “Fight the Fat”.

Research has revealed the magnitude of the health problems in our country, namely:• One in every six persons has diabetes. The highest incidence in the Caribbean and possibly the Western Hemisphere.

• Heart Disease accounts for 25% of mortality.

• 55% of our population is obese or overweight.

• We spend about $500 million per year treating diabetes.

• A significant percentage of our GDP goes towards treating Chronic Non Communicable Diseases.

• Dr. Mandrekar Bahall, a cardiologist at San Fernando General Hospital, research in 2011, has demonstrated a 1300 percent increase of Acute Myocardial Infarction over a 53 year period from 1958 to 2011 from 27 cases to 330 cases.

The underlying cause of Chronic Non Communicable Diseases

is obesity. But what are we doing to reduce obesity? For the past 20-30 years we have been chanting the mantra of “Eat less Exercise more” and the results are unimpressive.

On the other hand, what is the fast food industry doing? One of the seven wonders of the world, the Golden Arches of Mc Donald’s now grace thirty thousand (30,000) restaurants in 119 countries, an empire on which the sun never sets. Mc Donald’s missionaries spread the gospel of high volume, low cost and tasty food. Mc Donald’s continue to infect Chinese culture with 100 new Mc Donald’s outlets a year. That is, one new Mc Donald opening every 3 ? days. Now that the Great Wall of China has been cracked; can the Taj Mahal be far behind? Will India’s sacred cows become sacred burgers? In the local scene KFC, the fast food giant has over a 35 year period – built 12 regional KFC restaurants and 54 regular restaurants. KFC has invaded the citadel of learning, UWI and sits in the sanctum sanctorum, having created an endearing relationship between KFC spicy taste and the student’s palate. Some of our recent graduates have gotten so obese that they are ideal candidates for bariatric surgery to reduce their weight. The underlying cause-the devil- is fat.

But what is fat? Simply put, fat is food around the waist waiting to be used. Every iota of fat around the waist can be traced to something you ate in the past. You cannot build fat without food.

You cannot build it with good mind, bad mind, or genes.

It is food! So if you are a child of KFC, you have KFC fat around the waist; if you are a pelau person you have pelau fat around the waist; if you are a Hindu priest you have dhal and rice fat around your waist. But fat is not bad, it is a part of your property; it is part of your investment portfolio. You took your money when food was relatively cheap and bought extra. You sat, you ate and you enjoyed it. The body used what it was supposed to use and converted the extra you ate to fat for future use. And that was a good thing in the past. So if a famine came you lived off your fat, if winter came you lived off your fat, if hurricane came and destroyed all the crops, you lived off your fat, and if floods came and destroyed all the plants, you lived off your fat. If an earthquake came and you got covered by rubble and you got some air you lived off your fat.

So fat was a survival mechanism, which served us well in the past But it has now become our biggest medical challenge?

But how are we going to change our eating habits?

What we eat is determined by what is readily available, what is affordable, what tastes good and what does not conflict with religious beliefs. What are the pre-requisites for changing ones eating habits? It is naïve to think that the provision of medical education will cause change in eating habits. Even when medical information is clear, the range of effects it can have varies from random attention, to understanding, to analysis, to acceptance or rejection.

To effect change, one has to understand the patient’s traditions, religion, core beliefs, norms and their economic circumstances.

These are some of the factors that influence what our patients eat. The understanding –of which- will influence what we prescribe.

The recommendation of what to eat must be culturally sound, must be tradition-sensitive, affordable, religiously appropriate and the calorie content must be adequate for their energy demands.

We have to move from cultural blindness to cultural competence and from religious indifference to religious understanding. If we 59

Caribbean Medical Journal T&TMA INAUGURATION DINNER 2012

make an effort to understand our patient they will be more willing to understand us. For as cultural and traditional differences widen between patient and doctor, so do difficulties in communication and the ability to effect change arises. Research has shown doctors can effect profound changes on the lives of their patients. Their messages for change have to be short, simple, clear and concise.

They must be pleasantly repetitive. A simple measure of taking your patient’s weight every two months and encouraging greater effort to lose weight if they gain weight. But if there is even a small weight loss, you have to pour out copious amounts of congratulations. You kill them with praises. You have to prescribe meals that are balanced and low in calories. Meals that are affordable and appeals to their palate, tradition, culture and religion. In a diet dominated society, where slimness is relentlessly promoted as attractive, convincing our patient to lose weight should not be a difficult proposal.

The herbalists are having a field day because we are failing to fulfill our patient’s needs. But what do we do? We condemn the herbalist who uses charisma and charm to lure his clients of their hard earned cash. We, on the other hand, treat our patients with diet sheets. If there is no weight loss we promptly refer them to the dietitian. Obesity has now become the orphan child of the medical profession. Years ago it was felt that it was a psychiatric problem, but then the psychiatrists – having failed to treat obesity – decided that it was an endocrine problem. And referred it to the endocrinologist. The endocrinologist- having failed- washed their hands and referred it to the dietitian, where it languishes today.

There is no specialty to treat obesity, and if a doctor dares to treat obesity he is viewed with skepticism, he is viewed as a charlatan, as a merchandiser of snake oil. But we cannot shirk our responsibilities for much longer. The Governments of the CARICOM region expect the medical profession to reduce the incidence of Chronic Non Communicable Diseases by 25% in 2025. It is becoming an economic burden, a burden that becomes more and more unbearable as the years go by. We have to become less academic in our approach and more charismatic in our interactions with our patients. We have to become merchandisers of beauty, good health and happiness. We have to recognize that with a sweet tongue and nutritional knowledge in the head we can transform ugly ducklings into beautiful swans.

We have to become more visionary for if the mind cannot conceive the hands will not achieve. We have to advocate eating regimes that guarantee weight loss. For there is no pill, no substance, no injection, no vaccine that will achieve weight loss. So you have to become a calorie accountant.

You have to go back and study food and their calorie content.

Because if you prescribe weight loss regimes and if the patient adherence to your prescription does not achieve the promised results, your patient will lose faith in you. n other words your prescription must be sound. You must have faith in it, for if you believe it works, you can preach it. But better still if you live it, you can indoctrinate it. And if you live it, you become their role model. You have to become the embodiment of your message.

For if you portray the message they will embrace the message.

60

This year, 2012 doctors are blessed. Trinidad and Tobago and indeed the world are faced with the burden of Chronic Non Communicable Diseases that account for 60% of the world’s mortality. But seemingly insurmountable problems are golden opportunities in disguise. We have a golden opportunity not only to promote life style change- to reduce the incidence of diabetes, hypertension, cancer, strokes, heart attacks, sleep apnea, infertility, osteoarthritis and save our patients unnecessary medical expenses.

Lifestyle changes will improve the quality of life, ameliorate these conditions and prevent premature death, but it will not necessarily lead to life extension. The greater good will be life extension because as the weight and BMI goes up the life span reduces; and as the weight and BMI reduces, there is life extension.

The most promising option is a low BMI coupled with a healthy lifestyle which includes moderate exercise. The good news is that the “Wellness Revolution” as proclaimed by the Minister of Health, has begun. Frank Ramlakansingh and his group including the Minister of Finance have started the revolution burning up the Blanchiesseuse road with their exercise routines.The Portof-Spain axis which includes the hospital administrator Kumar Boodram and the Chief of Staff, Dr Collin Furlonge, have started the “Wellness Revolution” on Chancellor Hill. Kumar Boodram with the ancillary staff is blazing a trail, having lost 40 pounds.

The former president of the IRO Pundit Mookram Sirjoo who is with us is also on Chancellor Hill and has lost 20 pounds. Dr. Anthony Chang Kit and Dr. Boysie Mahabir have just bought their hiking shoes to join the Chancellor Hill group.

Our Police Commissioner, Dwayne Gibbs is also hiking up Chancellor Hill and promises to start the “Wellness Revolution” in the Police Force. The Minister of Housing has quietly started the “Wellness Revolution” in South and looks fitter and trimmer.

The Minister of Education continues to walk around the Queens Park Savannah and hike up Chancellor Hill .He has started the revolution in the school feeding program which will help to inculcate healthy eating habits in the school population which will have long term health benefits.

As we are all aware, prevention is the most cost effective way to treat Chronic Non Communicable Diseases. It gives me great pleasure to give the commitment on behalf of TTMA that we fully support, endorse and promote the “Wellness Revolution”.

With your permission I ask you to join me in a simple prayer God, give us the power to recognize that good health is not a matter of chance, but choice, not nature, but nurture, not eating what is available or traditional, but making appropriate food choices.It’s not the cards that Mother Nature has dealt us but how well we play them that determines the final outcome.

That our fault, dear Brutus, lies not in the stars but in our plates, That with every snack, every meal we make important fuelling decisions that we control, decisions that will determine our fate in the long run. Dear God, empower our physicians with thy grace and thy wisdom so that they can reshape the harmful behaviors of those in their charge.

God Bless.

Caribbean Medical Journal T&TMA INAUGURATION DINNER 2012

The Trinidad & Tobago Medical Association confers its most prestigious award to Dr. Solaiman Juman At its Annual Inauguration dinner on 28 January, 2012 at Crowne Plaza Hotel the Trinidad & Tobago awarded the Gold Pin of Honour to Dr. Solaiman Juman FRCS for his services to the Association. Prominent Otolaryngologist, Dr. Austin Trinidad FRCS delivered the citation on behalf of Dr. Juman: “The Honourable Minister of Health and Dr. Mrs. Khan, Mrs. Zalyhar Hassanali, President of the TTMA Dr. Maria Dillon Remy.

President elect Dr. Dev Ramoutar and Mrs. Ramoutar distinguished guests friends colleagues and well wishers Ladies and Gentlemen.

I have the very pleasant task this evening of introducing my friend and colleague Solaiman Juman or Solly as we all know him. I first encountered Solly when he did his internship at the San Fernando General and he was drafted into the South Doctors’ Cricket team as one of our pace bowlers and was part of our winning side in 1986. One morning he came to see me in the ENT theater saying he was checking out a career pathway. I of course always on the lookout for young talent invited him to work in ENT ( I say young talent even though Solly had more gray hair than I did and still has). And so began a long and lasting friendship. I hope I was instrumental in Solly choosing to become an Otorhinolaryngologist.

He stayed with us for about a year and a half and then went to the UK in 1990. He spent 5 years there and came back with two FRCS diplomas in General and ENT Surgery. He was also productive in other areas as he produced three children during his stay there.

Naturally at this stage I’ll mention his lovely wife Annie who has in no small measure contributed to Solly’s success. Solly has been one of the bright lights of the Medical Association. Apart from his extremely successful year as President he has continued to promote the Association on all fronts: As Editor of the CMJ, Chairman of

The Honourable Minister of Finance Mr. Winston Dookeran and Mrs. Dookeran, Mr. & Mrs. Shareef Juman, Awardee Dr. Solaiman Juman & Mrs. Vareena Juman, President of The Medical Board of Trinidad & Tobago, Professor Surujpal Teelucksingh and Mrs. Teelucksingh.

Incoming Executive.

the MPS committee, chairman of the CME committee (AACME Accreditation). So unlike many past presidents who serve their year and then fade away he has continued to serve the Association in a myriad of fronts. He is also a Vice-President of the Commonwealth Medical Association responsible for the Caribbean and Canada and is responsible for TTMA becoming a member of World Medical Association.

In Otolaryngology, he is a past president of Trinidad & Tobago Society of Otolaryngology & Head and Neck Surgeons (TTSOHNS) and the Caribbean Association of Otolaryngology (CAO) representative to the International Fedration of Otorhinolaryngological Societies (IFOS). Of course his day job is Lecturer in Otolaryngology at UWI and through his UWI Connection he has spearheaded for TTHONS the establishment of a DM Programme in ENT. Solly is also the host of Doctor in the House on IBN. It is an informative public education forum and is very popular. I can’t let this opportunity pass without mentioning the stale jokes section. My daughter who watches with me always says “Dad send some good material to Uncle Solly”. Of course he has rejected my jokes as unsuitable for a family show. Solly is very academically inclined and he has been my regular companion to the annual meeting of the AAOHNS in the US. Solly has presented two papers at this prestigious meeting. He has also authored several other publications. So you can see why we are fortunate to have him as our Journal editor and CME chairman.

Now you would imagine that he has enough on his plate to keep him out of trouble. Actually he also finds time to be a Political activist. I’m not going to mention which political party just to say it is not the one in opposition. The T&TMA, in honouring Solly has taken the unprecedented step of going straight for gold. Ladies and Gentlemen I am proud to present my friend and colleague Solaiman Juman – the recipient of the Trinidad & Tobago Medical Association’s highest award –the Gold Pin.”

Incoming President, Dr. Dev Ramoutar and the Outgoing President, Dr. Maria Dillon-Remy.

Former First Lady and Honorary member of the T&TMA, Mrs. Zalyhar Hassanali.

Generation Next.

Senator Dr. Victor Wheeler.

61

Caribbean Medical Journal

T&TMA Medical Research Conference The Trinidad & Tobago Medical Associationâ&#x20AC;&#x2122;s Annual Medical Research Conference was held on 1 July 2012 at the Hyatt Hotel It was a major success with over 350 attendees listening attentively to a wide variety of Medical topics. The Honourable Minister of Health, Dr. Fuad Khan was in attendance and gave an insight into new developments in the Ministry of Health.

The Programme was interesting and wide in scope ( See Table 1), with both senior and junior researchers participating.

Congratulations to Dr. Kirby Sebro for winning the award for the best Resident Presentation( Nutcracker Syndrome), just edging out Dr. Nazreen Bhim (Cervical Cancer).

Professor Terence Seemungal was presented with the Medical Research Award for his lifetime achievement in Research. Past recipients of this award include Professor Rolf Richards, Professor Courtenay Bartholomew, Professor Sam Ramsewak, Professor Vijay Naraynsingh, Professor David Picou and Dr. Alan Patrick to name a few.

Attendees to the Medical Research Conference.

Professor Naraynsingh holding court.

Congratulations to Dr. Lester Goetz, Dr. Stacey Chamely and the hardworking and dedicated office staff â&#x20AC;&#x201C; Ms. Mala Persad, Ms. Alicia Ramlakhan and Ms. Christina Rogers.

Professor Maughan ( Johns Hopkins) & Professor Seemungal.

Professor Terrence Seemungal receives The Research Award from the T&TMA President, Dr. Dev Ramoutar.

Dr. Pravinde Ramoutar & Dr. Lester Goetz.

Dr. Kirby Sebro is awarded the prize for the best Resident Presentation by Dr. Solaiman Juman.

Dr. Alan Patrick and Dr. Helene Marceau-Crooks.

Professor Sam Ramsewak (Dean of the Faculty of Medical Sciences, UWI) and the Honourable Minister of Health.

62

Secretarial Staff having lunch.

Caribbean Medical Journal MEDICAL RESEARCH CONFERENCE

Table 1.

PROGRAMME SESSION 1 Chairman – Dr. Muhammad Rahman- North Branch 8:15 – 8:25 am 8:25 – 8:35 am 8:35 – 8:45 am 8:45 – 8:55 am 8:55 – 9:05 am 9:05 – 9:15 am 9:15 – 9:25 am 9:25 – 9:35 am 9.35 – 9:45 am 9:45 – 9:55 am 9:55 – 10:05 am 10:05 – 10:15 am 10:15 – 10:25 am

Breast Cancer and Mammography – Dr. Maria A. Gosine New Cancer Care in Trinidad and Tobago – Dr. Pearse Sylvester Cervical Cancer – Dr. Nazreen Bhim Voice Restoration – Dr. Solaiman Juman Greetings from the Minister of Health – Dr. Fuad Khan HIV Care for patients in T & T – Dr. Alana Lum Lock Urinary Tract Infections – Dr. Virendra Singh Patent foramen ovale – Dr. Shane Gieowarsingh New Cardiac Unit in T&T – Dr. Pravinde Ramoutar Carotid Artery Intima media in Tobago – Dr. Alan Patrick Newborn Babies – Acute Phase Reactants – Dr. Arlette Khan Sperm Morphologies – Ms. Natalie Jess Nutcracker Syndrome – Dr. Kirby Sebro

SESSION 2 Chairman – Dr. Arnaz Macuum – Central Branch 12:00 – 12:10 pm 12:10 – 12:15 pm 12:15 – 12:25 pm 12:25 – 12:35 pm 12.35 – 12:45 pm 12:45 – 12:55 pm 12:55 – 1:05 pm 1:05 - 1:15 pm 1:15 - 1:25 pm 1:25 – 1:35 pm 1:35 – 1:45 pm

Citation for Awardee – Dr. Alan Patrick Medical Research Awardee – Prof. Terence Seemungal Chest Disease and Spirometry – Dr. Shiva Jaggernauth Inhaler Use – Dr. Michelle Trotman Hepatopancreatobiliary Surgery – Dr. Ravi Maharaj Triple Negative Breast Cancer – Dr. Jamie Morton-Gittens Cataract Surgery – Dr. Ronnie Bhola Obesity in Children – Dr. Beni Balkaran New Endoscopy Service in Trinidad and Tobago – Dr. Rene Ramnarace (T&T/Cuba) Prostate Cancer & Brachytheraphy – Dr. Trudy Kawal Burnout among residents in training – Dr. Satyendra Persaud

SESSION 3 Chairman – Dr. Liane Conyette- South Branch 3:15 – 3:25 pm 3:25 – 3:35 pm 3:35 – 3:45 pm 3:45 – 3:55 pm 3:55 – 4:05 pm 4:05 – 4:15 pm 4:15 – 4:25 pm 4:25 – 4:35 pm 4:35 – 4:45 pm

Orthopaedics in the state of Emergency – Dr. Viren Solomon Diabetes – Self Care – Prof. Felicia Hill-Briggs New Breast Service – Dr. Rajen S. Rampaul Liver Surgery – Dr. Celestine Ragoonanan Sperm Donors – Ms. Melissa Pereira Advances in Surgery in Trinidad and Tobago – Prof. Vijay Naraynsingh Cochlear Implantation – Dr. Howard Francis (USA) Open Heart Surgery – Dr. Randolph Rawlins Women with stress incontinence – Dr. Kirk Gooden

63

Caribbean Medical Journal

University News The Honourable Kamaluddin Mohammed In 2012, the University of the West Indies conferred honorary doctorates to many distinguished individuals of the soil.

One of those honoured was a past Minister of Health, the esteemed Kamaluddin Mohammed.

The Orator of the University, Professor Surujpal Teelucksingh introduced him to the audience.

“Mudhe lak burah cha-hay to kya hota hai, wohi hotay hai jo manzuray khoda hota hai” Chancellor, this is an URDU benediction that has echoed across the airwaves of Trinidad and Tobago since the 1940’s. It was introduced into the local lexicon by a pioneering, self taught, polymath with a melodious and captivating voice.

Kamaluddin Mohammed was still a teenager when he entered into community service and became The Imam at the Queen Street Mosque, in Port of Spain. Though his formal education ended only at the secondary level, he was already fluent in Arabic, Hindi, Farsi and Urdu. At the same time when the Indian Motherland was being torn asunder by partition, it was ironic that a grandson of the Kala Pani crossing was uniting Hindus and Muslims in far off Trinidad and Tobago. What was his instrument of unity, you might ask? It was a radio show called “ Indian Talent on Parade”. Using this medium he had produced a vent and vehicle for previously repressed cultural expression. But the radio station was too small for a man of such energy so he quickly turned to a much larger and challenging stage-- the national political platform.

For 30 years continuously, he served the people of this fair land as a member of Government and Cabinet of Trinidad and Tobago, in portfolios as diverse as agriculture , external affairs and health. He brought tremendous energy to his work and performed with distinction. It was under his stewardship as Minister of Health that the Mt Hope Medical School was conceptualized and it was he who ensured that it was brought to fruition. Though there is much more for him to choose from, he believes that his nomination to Chair of the United Nations World Health Assembly for two terms is his crowning achievement. It was during his tenure in 1978 that the World Health Organization adopted the very noble mantra of “Health for All” at the Alma Ata Conference, a slogan that emphasized health as a universal and fundamental human right.

Williams. From this association and vantage point he gained the opportunity to build friendships and relationships with influential men and women from around the world. These intimate connections were instrumental in lobbying our independence efforts which have inevitably shaped our destiny. Though he may have walked with kings, he has never lost the common touch. Take the words of his cabinet colleague Errol Mahabir, “Kamaluddin Mohammed has always led a simple life and humility has been one of his attributes. He has served his country faithfully and with a great sense of dedication”.

And then at the passing of Dr Eric Williams, everyone expected him to succeed as Prime Minister but to many it seems that he was unfairly bypassed. Much has been written and said over this apparent slight, but there has never been a word of rancour or regret from this statesman! Whatever his weaknesses, being a victim is not one of them. With tools of a sharp mind and a broad intellect, this servant of the people has built a great life.

It was hardly surprising therefore that he was awarded the Nation’s highest honour in the Order of the Trinidad and Tobago in 2010.

Chancellor, radio announcer, Imam, politician, statesman and speaker of five languages; the common theme amongst all of this versatility is the gift of a sensitive communicator. Here is a man who possesses the great ability to connect with ease at a deeply emotional level with his fellowman - be he King or commoner. This is his gift- a gift which he has put to extraordinarily good use. Our nation and our people have been enrichened by him.

When you receive him Chancellor and confer upon him the title of Doctor of Laws, honoris causa, …in the ensuing silence…..these URDU words will reverberate around this hallowed hall and the wider world:

Kamal was a close friend and confidante of the late Dr Eric

“Adha Barz Khoda Hafiz Phir Melinge.”

64

Caribbean Medical Journal

Meeting Report Trinidad and Tobago welcomes….. the Commonwealth!

Dr. Stacey Chamely In December 2011, the T&T Medical Association sent me packing to represent us at the Commonwealth Medical Association (CMA) meeting in Nairobi, Kenya. Thirty-six hours of flying later, I figured I’d better do some reading on what the meeting on Non-Communicable Diseases (NCD’s) was hoping to accomplish.

I suspect most of us don’t know that the Commonwealth makes up one third (1/3) of the world’s population – a whole lot of people (roughly 2.2 billion in total)! The CMA was established as a subgroup of the World Medical Association (WMA) in 1962. Incidentally, the T&TMA was inducted as the 100th member of the WMA in 2011, and our own Dr. S. Juman is the Vice President of the CMA. The CMA represents 54 countries and its health ministers meet in Geneva once a year to discuss issues related to the health of the diverse populations in our countries – that being said, if the Association would like to ‘send me packing’ to Geneva this year – I accept! :) Lately, the hot topic for discussion is NonCommunicable Disease.

All eyes on T&T: In 2007, there was a CARICOM Heads of Government meeting held in our very own T&T. At this meeting, the Declaration of Port-of-Spain: Uniting to stop the epidemic of Chronic NCD’s, as made. Fast-forward to November 2009, the Commonwealth Heads of Government (we all remember the traffic disasters caused in preparation for CHOGM) meeting again on our shores made a statement to “address the burgeoning incidence of NCD’s on the Commonwealth countries,” which it deemed to be a “serious threat to global health and to sustainable development.”

Why NCD’s? Good Question!

In 2011, the WHO global Health observatory ( http://apps.who.int/ghodata/ ) noted that four major diseases caused 80% of deaths due to NCD’s in all WHO regions, these are: 1. Cardiovascular Disease 2. Diabetes Mellitus 3. Cancer 4. Chronic Respiratory Diseases These four major NCD’s account for most of the 35 million deaths per year worldwide, most of which occur in mid to low income countries. To put it in perspective, approximately 9 people die every minute of communicable diseases (HIV/AIDS, Malaria and TB) but 68 people die per minute of NCD’s

WHO Global Status Report 2010 The major risk factors identified in this table overlaps all four of the NCD’s – tackling these could reduce much of the burden of disease fraught by the top four. (Source: Taking up the challenge of NCD’s in the Commonwealth) The Commonwealth Ministers in their 2011 meeting in Geneva also included on the list of NCD’s Mental Health; Blood disorders; Injuries; Violence and Oral Health as ones to watch per say. ….and back in Kenya: So I sat there in the lovely Sarova Panafric Hotel in Nairobi and listened to all my new friends from all over the globe share their NCD statistics and country visions with us. Each country had to give a report – let me take this opportunity to thank Dr. Kumar Sundaraneedi and Pofessor Surajpal Teelucksingh for supplying me with 2011 statistics on Trinidad from the population census and study on childhood obesity and DM respectively.

About the other countries, well I took notes and wanted to share some of what I learned: Kenya: their population is 38.6 million people of whom 5-10% have Diabetes Mellitus and almost 45% have Hypertension. In fact, 40% of their hospital mortality is attributed to NCD’s. To the Kenyan doctor’s chagrin, the first Mc Donald’s had opened that year in Kenya and it was felt that the proverbial floodgates were about to burst open in allowing fast-foods to dominate an already struggling population. They spoke about a dream for each health centre to have a blood glucose monitor – not point of care testing and facilities for HbA1c measurement as we have, but just a simple ‘finger-stick’ machine to help them with early diagnosis of DM! How’s that for 20/20 vision!

South Africa: Approximately 6 million people in SA have DM. One of the Government priorities there is to increase the South African life expectancy to age 53 in men, and 55 in women – hmmmm, makes us rethink the “live long and prosper” adage!

Ghana: a 2010 population consensus here estimated that of the 26 million people in Ghana, only ~6.3% of them are >60 years old. Here, there is 1 doctor, for every 11, 929 people.

Malta: They have a population of 400,000 of which, 900 are Doctors!! There are eight regional health centres – three of which offer 24 hour services and all heath care and medicines are free. However, this utopia is misleading; they also have the largest population of obese children in the world.

65

Caribbean Medical Journal TRINIDAD AND TOBAGO WELCOMES….. THE COMMONWEALTH!

Rwanda: With a population of 1.1 million, this country ‘boats’ 600 doctors (only 1:18,000 inhabitants). The #1 NCD in Rwanda is NOT Cardiovascular disease, but instead neuropsychiatric conditions (4.3% of the 17% disease burden of NCD’s) – most of which are attributed to the Rwandan genocide. In Rwanda, 20% of women have a BMI consistent with malnutrition!

Sri Lanka: people there are short, very, very short. The doctors there are now considering devising their own BMI and waist circumference scales as the current ones do not apply to their population.

Uganda: There was little or no data for this country prior to 2005 due to Edie Amin’s reign of dictatorship. All their statistics were estimates, but it was felt that poverty was their main barrier to combatting NCD’s – medicines for DM and Hypertension are not available in anywhere between 30 – 90% of government health facilities.

As a result, 80% of their patients seek the services of “traditional healers”. Sounds familiar? (……..and we have the medicines available for free!)

India: With a population of 1.2 billion, India is referred to as the epicentre of the “Diabetes Quake.” Their 2012 goal is “Primordial prevention” – to stop DM in the womb by screening all pregnant women for DM (and Hypertention). Interestingly, the monthly household expenditure of tobacco was three times as much as that for nutritious food among street children in Mumbai – a scary statistic indeed for the prevalence of Chronic Respiratory Diseases in their future.

Tanzania: Diabetic Ketoacidosis is a common emergency with a 25% mortality rate – why? Insulin is not always available in hospitals ………

I could go on and on. Needless to say, in every country, big or small, prosperous or poor, the health issues were very much similar. The approaches to same however, were not – and so the discussions about how to tackle NCD’s as a Commonwealth must continue. It is on this note that we are proud to say that the T&TMA will host these and other Commonwealth states to discuss “NCD’s – the way forward” in the CMA’s 23rd Triennial Conference on June 29th 30th 2013, right here in T&T. We hope to have delegates from all over the region and around the world, and expect to see you all there.

Asante sana!

Dr. Stacey Chamely CME Coordinator, T&TMA

66

Caribbean Medical Journal

Obituary Professor Hari Maharajh Professor Harrinath Maharajh died on February13, 2012 after a prolonged illness at the Eric Williams Medical Sciences Complex. He left a wife and two children as well as the Medical and Psychiatric communities to mourn his passing.

“Hari”, as he was known to most of his colleagues had a colourful and praiseworthy career.

He was born in Tableland and after Advanced Levels, obtained a degree in Zoology from the University of Manitoba. He returned to Trinidad in 1971 and taught for one year before entering the Faculty of Medical Sciences, University of the West Indies (UWI) Mona, Jamaica in 1973. He graduated in 1978 and after internship began his career in Psychiatry, working as a House Officer in St Ann's Hospital, the country's only mental hospital.

He then obtained a Government scholarship to study Psychiatry in London in 1981 and completed his membership in Psychiatry (MRCPsych) and also a Diploma in Clinical Neurology in 1984 and 1985,respectively. He returned to work in St Ann’s Hospital becoming Medical Chief of Staff in 1998.

He founded the Transcultural Society in 1988 and through this society organised several functions to honour the diversity that

exists in Trinidad and Tobago. He was also a founding member of the Association of Psychiatrists of Trinidad and Tobago (APTT). He became President of the Trinidad and Tobago Medical Association (TTMA) in 1998. He had been the long standing Editor of the Caribbean Medical Journal and contributed immensely to the Journal's growth.

He was appointed Senior Lecturer in Psychiatry in 2001 at the St. Augustine campus of the University of the West Indies and was promoted to Professor in 2010. He was very popular among the students and devoted much of his time to interacting with them.

He was University Examiner in Psychiatry between 2008-2011 and supervised the graduation of several psychiatrists and Masters level Clinical Psychologists.

Professor Maharajh published over 50 articles and book chapters and two books including the internationally published- Social and Cultural Psychiatry- experience form the Caribbean in 2011.

His major academic interest was related to the interaction between culture and mental illness as well as the intersection between Psychiatry and Neurology. His other book was Neurology for Students.

He longed for the advocacy and development of a Caribbean Psychiatry, that would contribute to the evolution of a method of practice that reflected the unique experience of Caribbean people. His contributions to the discipline of Psychiatry were profound and his absence leaves a void that would be difficult to fill in Trinidad and the wider Caribbean.

67

Caribbean Medical Journal

Taking it Easy The art of medicine Presented by the Art Society of Mt. Hope The Faculty of Medical Sciences of The University of The West Indies, Trinidad has one of the most prestigious medical schools in the Caribbean region. However, the prowess of its students is not limited to academics and includes other talents. An example of these was represented recently by the newly formed club, The Art Society of Mt. Hope. This club, led by its current president, Srikanth Adidam Venkata, a fourth year medical student, was formed to showcase the hidden talents and passions of the students and faculty. The formation of the Art Society was greatly supported by the Faculty and the Guild of Undergraduates.

Dean of the Faculty of Medical Sciences, Professor Samuel Ramsewak admiring several pieces.

In an attempt to showcase the creativity of Mt. Hopeâ&#x20AC;&#x2122;s artistic individuals, the Art Society featured its Art Gala on the 9th February 2012. The inaugural Art Gala was a stunning success with almost one hundred and fifty pieces being displayed and faculty members, friends and family as well as other members of the public came out to enjoy this event.

The exhibition which was held at the Roof Top Restaurant at the Eric Williams Medical Sciences Complex showcased a wide range of visual art; media from pastels to charcoal and paint to ink, all manner of media were exquisitely portrayed. Genres included positivistic to abstract, traditional to impressionism and awoke vivid imaginations and reminiscent memories. Scenic birds and picturesque floral arrangements, with their masquerade of brilliant hues, brought a once dreary hall to life- like a movie theatre where only the sound effects were absent. So vivid was the imagery and exceptional the detail that some attendees reached out to touch the rustic abandoned houses and beautiful landscapes, their eyes drinking in the captured images. Black and white pieces exuded such vibrancy that many questioned as to whether these were medical students or in fact, professional artists.

Not surprisingly, many offers of purchase were made by the captivated patrons but these were declined by the artists, all of whom had strong emotional connections to their work.

The general consensus was that this should be the first of many such exhibitions and the Dean was heard asking how the Faculty can best support and nurture this effort.

Deputy Deans of PreClinical and Clinical Sciences, Drs Yuri Clement (L) and Ian Sammy (R).

68

Patrons at the show and a panorama of the gallery.

Other pieces on show.

Caribbean Medical Journal

Instructions to Authors The CMJ is an International peer-reviewed medical journal. The CMJ publishes original articles, case reports, reviews, position papers, editorials, commentaries, book reviews and letters. Other information relevant to medicine and related articles including local and regional medical news and international news that applies to the region will also be published.

Our Mission is to promote and develop medical publication from within the region. We also aim to stimulate doctors and other health professionals to make better decisions resulting in better patient care. The CMJ is the Journal of the Trinidad & Tobago Medical Association and the Editorial Board is based in Trinidad & Tobago. However, we have editors from within the region and internationally. CMJ accepts no responsibilities for statements made by contributors or claims made by advertisers.

Submission Guidelines Submissions All submissions and editorial communications should be sent online to the Editor, CMJ via medassoc@tntmedical.com Do not submit paper manuscripts. Hard copy/print versions will not be accepted.

The editor may not consider your submission for publication if the authors do not comply with the following instructions.

Text, tables and any imbedded artwork or photographs should be combined into one word processor file (.doc or .rtf are preferred).

Artwork and photographs should also be submitted separately as .jpeg files.

Submission Letter Should indicate (1) the contents have not been published or under consideration for publication elsewhere, (2) all authors have read and approved the manuscript and (3) there is no ethical problem nor conflict of interest.

This letter can be scanned and e-mailed or faxed to: The Editor,Caribbean Medical Journal, The Medical House, 1 Sixth Avenue,Orchard Gardens,Chaguanas, Trinidad, WI. Tel: 868 671 7378, Tel/Fax: 868 671 5160.

Language Articles must be written in English with adherence to either British or American spelling throughout.

Layout Submissions should be typed double spaced and all pages should be numbered consecutively.

Use 12 point font in Times New Roman style.

Images Any article that contains personal medical information or images that can identify a patient requires the patient’s explicit consent (appendix: Patient Consent Form) before they can be published. If the patient cannot be traced and consent is not obtainable then every attempt should be made to ensure that all information and images should be made suitably anonymous. This may result in a loss of information and detail.

Source of Funding All source of funding should be declared in an acknowledgement at the end of the text.

Article Categories a) Original scientific articles should contain in the following sequence: title page, text of article, acknowledgments, references, tables and legends. Each component should begin on a new page.

• The title page should carry (1) a concise main title and subtitle (if any), (2) the first name and surname(s) of each author and qualifications, (3) the department(s) and institution(s) where the work was carried out, (4) the name, e-mail, address, fax and telephone number of the author responsible for correspondence.

• The text of original articles is divided into sections with the headings Abstract, Introduction, Methods, Results and Discussion.

• The Abstract should not be more than 150 words with the headings Objective, Study Design, Subjects and Methods, Results, and Conclusion.

• References should be cited in the text as numbers in square brackets. Personal communications, websites and unpublished data should not be included in the list of references, but can be mentioned in the text only. All authors should be listed (use of 'et al.' is not acceptable). Journals should be indexed in, and their abbreviations conform to, Index Medicus. Please follow this reference style carefully. e.g.

Journals [1] Sanz G, Castaner A, Betriu A, Magrina J, Roig E, Coll S. Determinants of prognosis in survivors of myocardial infarction: a prospective clinical angiographic study. N Eng J Med 1982:1065-70.

70

Caribbean Medical Journal

Instructions to Authors Books [2] Huang GJ, Wu YK. Operative technique for carcinoma of the esophagus and gastric cardia. In: Huang GJ, Wu YK, editors. Carcinoma of the esophagus and gastric cardia. Berlin: Springer, 1984:313-348.

On-line-only publications.

[3] Kazaz M, Celkan MA, Ustunsoy H, Baspinar O. Mitral annuloplasty with biodegradable ring for infective endocarditis: a new tool for the surgeon for valve repair in childhood. Interact CardioVasc Thorac Surg. doi:10.1510/icvts.2005.105833. b)

Other types of articles such as reviews and editorials will vary in format.

Original and review articles should not exceed 5000 words. Editorials and commentaries should not exceed 1000 words and 15 references. Letter should not exceed 500 words and 5 references. Generic names must be used for all drugs. Measurements should be given in the units in which they were made, but non- metric units must be accompanied by SI equivalents.

The Review Process.

Acknowledgement will be sent to the corresponding author on receipt of submissiom. Each submission will be assessed by at least two reviewers, who are to treat papers as confidential communications and not to share their content with anyone except colleagues they have asked to assist them in reviewing, Submissions are judged on their clinical importance, scientific strength, clarity and accuracy. The main author will be informed of the decision about the submission via electronic means. The Editors retain the right to style and to shorten material accepted for publication.

Caribbean Medical Journal Patient Consent form Name of person in image:

Title of Manuscript:

Corresponding Author:

I {insert full name] give my consent for the information about MYSELF / MY CHILD / MY WARD / MY RELATIVE [circle relevant description] to appear in the CMJ. I understand that: • The information will be published and that every attempt will be made to ensure anonymity. Despite this, it is possible that I may be identified (for eg, by someone who looked after me in hospital).

•

The information will be published in the CMJ and is seen mainly by doctors. However, non-doctors may see it.

•

The CMJ will not allow the information to be used for advertising or out of context.

Signed:

Date:

71