Minutes ago, a turtle bigger than my dog bumped into me. I looked down to catch a glimpse and saw it drift up from beneath my legs, chasing after dozens of huge fish. I am definitely not known for my swimming, so it’s with some surprise I found myself floating forty feet above the Caribbean sea this afternoon.
Minutes before that, I was staring out across the sea from a little boat, counting other bigger boats. There were at least a dozen in view. They almost looked like they were hovering, the water was so clear. Today marks my last day in the Caribbean, finishing it as I started, at a beach house. However, in an attempt to escape its soundtrack (Worst of the 90s, also feat. Abba and Justin Bieber), we had gone looking for some turtles. But more on that in a minute.
A lot has happened in four weeks. When I came, I was the picture of a Brit abroad, complete with DEET-laced shorts and a hat that wouldn’t look out of place on safari. This sadly remains unchanged. But I do feel like the Caribbean has brushed off on me in other ways.
I’ve seen so much more than I ever thought I would, inside the hospital and out. I’ve learned about a population with incomparable friendliness (I thought I was laid back. Now I know the true meaning of chilling), but have been privileged to also learn about their many and varied health problems.
With widespread hypertension, some of the most poorly controlled diabetes worldwide, and a seven fold increase in some blinding eye diseases, Barbados doctors have more than their fair share to deal with. It makes me really appreciate how far along the UK is in its healthcare, particularly with regards to nipping disease in the bud before it grows out of control – including our close diabetes monitoring and retinal screening service.
It’s shown me that it’s always important to look at things from another perspective. Like, say, going snorkeling for the first time instead of lounging on the beach. Which takes us back to me bobbing along next to my little boat.
Staring down at the sea floor was incredible. Schools of fish, each one as big as my foot, darted around anywhere I cared to look. I’ve never seen anything so vibrant, almost loud to look at. The turtles circled around me, coming in to see this clumsy, goggled invader. I could not get over how huge they were. Far too big to glide around so effortlessly. We brushed past each other a few times, and their shells felt like smooth rock. Floating there, over hundreds and hundreds of square feet of ocean floor, was a feeling I’ll never forget.
There’s a phrase that goes: ‘a comfort zone is a beautiful place, but nothing ever grows there’. I try to take this to heart. Whether it’s changing up your career plan and training as a doctor, muddling through your first long haul flight alone to work at a hospital abroad, or even colliding with a giant turtle, I think you can only learn by doing something new.
‘You see the white debris covering the pupil? The operation did not go as planned.’
As with anything in life, sometimes medicine can go wrong. All treatments come with their own risks and benefits, and it’s the job of a doctor to weigh out the scales and decide if a certain drug or operation will benefit the patient, or harm them. For the patient above, their outcome was not so favourable.
She had originally had a cataract (a clouded lens – found behind the pupil), and so had been scheduled for an operation to remove it and replace it with a new, synthetic lens. For a cataract as mature and opaque as hers, this would have meant a significant improvement in her vision.
In the eye, the lens sits within the lens capsule. In removing it from this capsule, sometimes the back of it (which faces the vitreous jelly in the centre of the eye) may become ruptured – a posterior capsule rupture. This is a well-recognised complication of cataract surgery and unfortunately occurred during this lady’s operation. A chief concern is that the lens may drift backwards into the vitreous, and so the surgeon had pulled the lens fragments forwards into the anterior chamber: the space in front of the pupil.
This explained the curious appearance of the patient’s eye: there were shards of milky white covering all the pupil and iris, almost like a paperweight pattern. This was what remained of her original lens, displaced and broken apart. Whilst this meant the lens stayed at the front of the eye, the patient’s vision would be negligible until a further operation to try to remedy the damage. They were also now at increased risk of glaucoma, infection and and retinal detachment, making close post-operative follow-up essential.
Throughout medical school, I’ve always tried to seize the times where I’ve been wrong as learning opportunities. In a way, I think I came to see getting something wrong as a ‘good’ thing, as it easily highlighted an area to improve. This is all well and good when talking about exam grades or write-ups, but I think it will be much harder to gather myself after my first real clinical complications.
There is a lot more at stake than just my learning – the situations where I make the wrong decision for patients will be the biggest challenges I’ll ever come across. Luckily I’ll always be part of a team to support me, and I hope that through them, these errors will be as rare as what happened to this patient.
Yesterday saw a welcome break from the norm – I made an actual, correct diagnosis. The patient, a gentleman in his late 40s with a curious blurring of vision in his right eye, kindly gave me excellent practice. He had a fixed stare, had already had his pupils dilated with special drops, and last but not least, his eyes were huge.
Years ago, in the daydream land of lectures, examining the eye sounded pretty straightforward. Basically you hold up a little instrument called an ophthalmoscope (or fundoscope – basically a magnifying glass with a torch) to the patient’s eye and try to peer at the retina. There’s little extras, like adjusting the lens, darkening the room, and awkwardly squatting down to the patient, but that’s the gist.
Nonetheless, despite having actually lost count of the number of times I’ve done this, it all too often feels like I’m just so focused on following the procedure that I’m not actually looking at what’s in front of me. It was tempting in most clinical exams to learn them like plays, making the right noises and tapping the right parts, but being more interested in your examiner’s pen-strokes than actually seeing what the patient’s body is showing you.
With this patient however, I was determined to try and actually work out what was going on. From the brief bits of history I’d managed to take, I knew his loss of vision was sudden, and that sometime beforehand, he had been struck in the eye. Trauma is an important thing to ask about, as the eye is made up of a lot of delicate parts that don’t respond well to things flying at them.
I had a suspicion of what was wrong, but it was important to try and see for sure. For a while it was the usual blurry mess. Eventually the vessels came into view, and then the optic disc (where the optic nerve enters the eye). It all looked fairly normal compared to a lot of eyes I’d seen – there were no haemorrhages (blood spills) or exudates (leaked fat) that you might expect from diabetes or hypertension.
Then, I saw a strange speckling that I presumed at first was a problem with my kit. It persisted, and I remembered hearing about a sign called ‘tobacco dust’: basically, these are small pigmented dots visible after a part of the vitreous (inner jelly) of the eye detaches from the retina – a posterior vitreous detachment. It commonly causes a full-blown retinal detachment with it, too.
With my face still practically touching the patient’s, I craned back to look at the retina again. Sure enough, just to the side of the optic disc, there was a little lightened segment that looked a little bigger than the rest, somehow. This was the piece of retina that had been pulled when the jelly had shifted, causing the man’s loss of vision.
The man was scheduled for an operation to repair the retina, solving a condition that would otherwise have meant permanent loss of vision. I think the biggest lesson I’m taking from the Caribbean is this skill: being able to finally recognise things instead of just politely acting examinations out. This is probably just as well with a year on the clock until graduation, though!
‘You see how the growth has grown across the eye? You’ll never see this in England.’
I’m in theatre again, scrubbed up and staring down towards our patient. Today, we are dealing with a pterygium, a benign growth of the conjunctiva. This is where the white of the eye grows inwards to the pupil, potentially covering the cornea and interrupting vision. This was the case for our patient today, and so he had been admitted to have it cut out.
The condition is also called ‘surfer’s eye’, owing to the fact that it is associated with prolonged exposure to ultraviolet light, sand and low humidity. Given you’d be hard pushed to even find the first two in the UK, it’s less of a mystery why it mainly presents in areas like the Caribbean.
‘Is it still stinging?’
The surgeon dabs gently at the eye with a cotton wool bud. As with any surgery, it’s crucially important to make sure the patient can’t feel anything before you start. With the all clear given, he proceeds to finely cut and scrape against the small, red growth. Slowly but surely, the cornea is unearthed.
The increased prevalence of pterygia is one of many variations I’ve picked up in eye disease between different populations during my stay. White patients are more susceptible to macular degeneration, for example, whilst black patients are more likely to develop open angle glaucoma. This diversity means that doctors must pay close attention to their patient’s background: whether ethnic, social or geographical. They can provide useful clues when you come to decide what disease the patient is most likely to have.
The fleshy pterygium is now completely cut out (excised), but this means that there is no longer any conjunctiva covering the area either. The underlying sclera cannot be left exposed, and so the surgeon takes a cut from the inside of the eyelid as a replacement. The graft is fixed into place with extraordinarily small sutures to complete the job.
It’s exciting seeing all these new and unusual conditions, but it’s also an important reminder that medicine is not the same the world over. Though I probably won’t be asking after surfing as well as cigarettes in my histories, I do feel better for knowing.
I feel like I’ve come a long way in two weeks. Stepping off the plane I had positively no clue where I was 90% of the time. Now, it’s more like 70%. In spite of my persistently awful sense of direction, I’ve squeezed a lot out of this weekend, including, but not limited to: a cave, a festival, a beach, and another jerk chicken burger. Let’s start with the cave.
Harrison’s Cave is hailed by many as the number one tourist attraction of Barbados. Formed from thousands of years of slow erosion of the limestone base of the island, these lengthy caverns actually require a full-blown tram to get around on. Certain bits are wired up with lighting to let you wander around on foot, too.
It was a beautiful and eerie sight. The caves were calm and almost serene – nothing could be heard save for the constant drips from the ceiling. I couldn’t help but wonder however what it would have been like to be crawling through here on my hands and knees, as the first explorers had. They had trailed the underground streams by torchlight in what must have been an incredibly exciting (and incredibly claustrophobic) venture.
Humbling as all this ancient rock was, our stomachs sent us back to Bridgetown. The roads had been closed off (thank god!), making it much easier to get around. That is, before bumping into a full-blown festival. This could hardly go ignored, and so we spent some time taking in the many and varied sights.
The next day, we headed out to Worthing Beach, along the south coast. I felt a little tense en route with the threat of another shower (read: monsoon). Instead, the Caribbean delivered yet another impossibly picture-perfect afternoon soaking up the sun. I had thought my tan was coming along rather well, but on looking to my well-bronzed friends, I must admit I may well still be the whitest person on the island. At least I’ve got plenty of jerk chicken to numb the pain. Here’s to the next two weeks!
One of the main reasons I came here was to explore a new culture. Although similar to the UK in some ways, Barbados has a distinct personality that comes out in the land, the people, and many places of interest. Reading about their road to independence felt rather topical in light of the recent EU referendum (NB: goodbye spending money!).
Barbados (from the Spanish los Barbados, ‘the bearded ones’ – allegedly describing the first Caribs) is a fairly small island at just 21 miles long, but has changed hands a lot. Originally it was inhabited by Amerindians from the Americas, then briefly visited by Spanish and Portugese, before finally being claimed in the name of King James I by English sailors of the Olive Blossom. It became independent state of the Commonwealth realm in 1966.
Walking around, you don’t have to look far to see British influence. Cars drive on the left, postboxes bear a royal logo, and there are a lot of places that pay homage such as Queen’s Park, created in honour of Queen Victoria. Originally, the area housed the British military general, back in a time where the island served as a key vantage point for skirmishes with neighbouring French or Spanish-held islands. Now, it’s a beautiful green space with many interesting things to visit, like this supposedly thousand-year-old Boabab tree, the seed of which is thought to have drifted over from Africa:
Another interesting place I came across was the Barbados Museum and Historical Society. This had a great section on natural history, explaining the progression of endemic species (plants and animals that had existed nowhere else in the world than in Barbados) towards a mixed habitat that included several invaders brought aboard ships. Several strange cross-fertilisations are thought to have occurred on the island, and it is unofficially credited with the creation of the grapefruit.
The main focus of their exhibits however were on the people of Barbados. With Britain as a model, the first hospitals, schools and police force were made with more nods to the monarchy. The emancipation of slavery of course makes up a great deal of the island’s history too, and this was sensitively and clearly explained.
In light of the Brexit saga today, what really interests me about seeing all of this is getting a glimpse of how Britain was viewed in the past. It was a huge body with many ‘assets’ to protect in the New World, and it took centuries for places like Barbados to move towards sovereign independence. But this is certainly not the case anymore. What was once a sprawling empire is now a very, very small part of a much bigger world.
I am very allergic to both politics and religion, but I can’t help but dimly remember a story from the drawl that was CoE primary schooling, the ‘Tower of Babel’:
Now the whole world had one language and a common speech. As people moved eastward, they found a plain in Shinar and settled there.
They said to each other, “Come, let’s make bricks and bake them thoroughly.” They used brick instead of stone, and tar for mortar.
And they said, “Come, let us build ourselves a city, and a tower whose top is in the heavens; let us make a name for ourselves, lest we be scattered abroad over the face of the whole earth.”
But the Lord came down to see the city and the tower which the sons of men had built.
And the Lord said, “Indeed the people are one and they all have one language, and this is what they begin to do; now nothing that they propose to do will be withheld from them.
Come, let Us go down and there confuse their language, that they may not understand one another’s speech.”
So the Lord scattered them abroad from there over the face of all the earth, and they ceased building the city.
Therefore its name is called Babel, because there the Lord confused the language of all the earth; and from there the Lord scattered them abroad over the face of all the earth.
To me, whether you’re trying to build a stairway to heaven or just get some cheaper flights to Germany, there is no use at all in pushing the world apart.
I had never realised how big sugar is in this part of the world. Tinned fruit has added sugar, the juices have added sugar, heck, even the milk has added sugar. Owing in part to its American imports, Barbados certainly has a sweet tooth.
Sat in clinic with me today was a lady whose life had been devastated by sugar. Her left leg had been amputated some years ago, and her vision was starting to decline due to damage to the vessels in her eye. She had diabetes mellitus, a condition where the amount of sugar in the blood goes uncontrolled – often due to being overweight. It translates roughly as ‘sweet urine’, after the sugary quality urine takes on when glucose levels climb too high. This was a hallmark sign used by early physicians (and perhaps some stranger ones today) in diagnosing diabetes.
How does this happen? As we touched on in an earlier post, sugar in the blood needs to be held in a delicate balance by hormones in order for the body to function normally. The reason it’s there at all is as an energy source: and so if levels decline, individuals can become drowsy and lose consciousness. However, when levels are too high (hyperglycaemia), damage to blood vessels can occur. This causes a host of problems depending on which blood vessels are affected.
For our patient, the vessels in her leg had become so damaged by poor sugar control that its tissues were no longer receiving blood properly, and so the leg needed to be removed so that it didn’t start to decay. Now, her eyes were at risk: the tiny vessels supplying the back of her eye (the retina) were starting to leak, causing dangerous swelling on a part called the macula. If the swelling persists, she will lose vision permanently.
All of these problems are made a lot better with improved control of diabetes, which can be achieved by lifestyle changes like losing weight, eating less refined sugary products and exercising more, as well as adherence to medication. This will lay the groundwork for the treatment of this lady’s eyes with a laser, which will hopefully plug the leaky vessels and reduce the dangerous swelling (a process called photocoagulation).
It’s definitely something I’ll be keeping in mind the next time I’m eyeing up one of the island’s many sweet treats. No-one wants to be facing the question: ‘How’s your sugar?’
‘He is homeless, you see. Had we given him the surgery, there would be no-one to look after him.’
My consultant and I discuss our last patient, an elderly gentleman with highly advanced cataracts. His pupils had shone white against my torch, indicating that barely any light at all was making its way to the back of his eye. In the UK these are operated on promptly, restoring vision and a great deal of quality of life. Here in the Caribbean however, the waiting list is vast – not to mention this man’s unfortunate home circumstances, which had forced back his own surgery.
Money is an uncomfortable reality of medicine. Every doctor, every drug, every machine is a resource with a cost. At medical school, we are taught to be mindful of how we spend such resources: e.g. don’t blindly order every blood test going, but try to hone in on what might be relevant. Our gentleman today was a stark reminder that a patient’s own social and economic background can also raise barriers. His simple need to have someone around to administer his post-operative eye drops had meant a huge upheaval of his very necessary treatment.
The Caribbean has worked hard to invest in its eye services however, which was apparent in another cataract patient I saw. This man’s cataract had been successfully removed, but he had suffered a complication called posterior capsule opacification. This is where the clear capsule from which the cataract was removed becomes unclear and itself causes blurring. This can be fixed with something called a YAG laser, which was ready and waiting at the hospital.
With the patient sat securely in front of the laser, I watched as my consultant carefully aimed and fired it through the affected eye, creating a tiny series of transparencies in the capsule. After literally a few seconds (albeit with some odd phutt noises), the patient was taken through to the examination room, where he proceeded to read from the chart straight away. Pretty amazing.
Money is, to most medics, an incredibly dull topic. Seeing results like this however, I can appreciate that it’s important to keep aware of finances – be it your hospital’s, or your patient’s.