Blogging Barbados: Independence

 

You don’t have to look too long before you find a bit of Britain in Barbados (Queen’s Park).

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:

One of the island’s two Boabab trees (Adansonia digitata), originating from Ginea in west Africa. It is 28 metres tall and has a girth of 25 metres.

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 Barbados Museum and Historical Society.

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.

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Blogging Barbados: Sugar

The view from a Glaswegian-built bandstand in Queen’s Park.

‘How’s your sugar?’

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?’

 

 

Blogging Barbados: Costs

An abandoned site near the hospital that I think made up the old complex

‘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.

 

 

Blogging Barbados: The North Point

In Barbados, getting to places is cheap. For $2 Bajan dollars, you can ride a (mostly intact) bus from one end of the island to the other. The main sticking point is knowing where on earth they all go. So it was fortunate that this weekend I was travelling with a great couple of fellow medics who, unlike me, had some sense of direction.

We were travelling to the very northern edge of the island (North Point) looking for a cave with animal-like flowers in it (the Animal Flower Cave). Barbados naming conventions are quite Ronseal. After an edge-of-your-seat-and-then-some bus ride from Bridgetown, we checked in to our new, pleasantly decorated subterranean complex …

The mysterious animal-like flowers were in fact sea anemones that were a little too tricky to photograph. But worry not, we also got some high-octane selfies hanging off a cliff edge (ignore the railing):

We then headed to Speightstown, a little further south along the island. The afternoon was rounded off perfectly by, in no particular order: a beach, a deck of cards, fried chicken, plantain, and a pancreas-withering 53g sugar Coca-Cola. What a wonderful island.

Blogging Barbados: Limits

‘I was using a spinning blade. It cut me, deep in my eye.’

I think we often take for granted the sheer complexity of what the body does. All too often in medicine, we simply do not fully know how things work – even paracetamol. My late granddad always used to say that it’s astonishing so many people are healthy when there are so many things that can go wrong. Sometimes it can happen with hardly any prompt at all, but sometimes, it follows a very serious accident.

I peer towards the gentleman in front of me. The blade has lacerated the right eye’s surface, giving a bloodied appearance and a bulging swelling. I shine my torchlight on its pupil, seeking in earnest for some kind of response. It is wide and unflinching, which means it cannot perceive light. Normally, a pupil constricts in response to light (a direct pupillary reflex).

I shine to the left eye, which constricts normally, and also causes a sluggish constriction of the right. This is a consensual reflex – the healthy left pupil can constrict the right pupil, but left to its own devices, the right is permanently dilated.

‘Look up, look down, look left, look right.’

The affected eye wanders slightly but stays fixed. As well as visual loss, this man has ophthalmoplegia – paralysis of the muscles that allow the eye to turn and rotate. The blade must have traveled deep: deep enough to damage both the visual and motor nerves of the eye.

Switching off the lights, I take out my ophthalmoscope and examine the inside of the eye. This is a tricky, but important skill to master. With just glass and light, you can observe nerves and blood vessels – something that cannot be done anywhere else in the body. A good ophthalmoscopy can reveal a slew of conditions, from diabetes to heart disease.

The retina is a patchwork of haemorrhages, with one huge pre-retinal haemorrhage visible as a sea of red. There is very little that can be done to improve this man’s vision with the technology we have, whether in Barbados, the UK, or anywhere. The only help we can offer will be drops to improve the discomfort and reduce the risk of infection.

Managing expectations is a big part of medicine. Truly, I think this man already knew his condition could not be helped. Sometimes however, patients overestimate what can be done. I am always optimistic that it will be sooner than we think that even injuries like this can be remedied. However, until then, one of the hardest tasks I think I will face is making patients understand where medicine cannot take them.

Blogging Barbados: Scrubbing Up

Local fauna rejoice, couldn’t go full-on tourist today. Here’s a shameless uniform selfie instead.

I’m sat in theatre staring down a microscope at the most delicate procedure I’ve ever seen. I watch as my consultant expertly wields her minuscule equipment on our patient’s eye, making the first of many tiny incisions.

One of the biggest decisions you have to make as a doctor is what kind of work do you want to do. Usually it’s pretty easy for people to decide whether they want something hospital-based or community-based. For the former, it’s much harder to decide between medicine and surgery. Some specialties, ophthalmology included, let you dabble in a bit of both.

The conjunctiva (outer layer of the eye), now fully resected, is folded back to reveal the capillary-rich sclera (another layer just slightly deeper). With eerie focus the consultant continues deeper, tracing around to the side of the socket.

‘You see that shiny bit? That’s the muscle.’

This patient has a disease called glaucoma, which is where the pressure of fluid inside your eyes increases so much that it damages the optic nerve behind it and causes loss of vision. He was scheduled for an aqueous shunt – the implantation of a tube into the front of the eye that would allow this excess fluid to drain (‘basically plumbing’ as the doctor modestly put it).

I watch through the scope as a tiny implant is sutured to the sclera, anchored between lateral and superior rectus, two muscles of the eye. Its little plastic tube is pierced into the anterior chamber (the clear fluid-filled space in front of the iris – the colourful bit). Now, the fluid can pass from the chamber safely into the venous drainage of the eye.

This is practically the only place in the Caribbean where this remarkable procedure can be done. There is a waiting list of a hundred patients or more. Any mistakes could be devastating – potentially robbing the diseased eye of what little vision it has left. The consultant shrugs off these pressures regardless, keeping themselves fixed in concentration.

I find surgery fascinating, but would always want to keep some variety, making ophthalmology increasingly appealing. Plus, as my consultant cheerily points out: ‘surgery’s a lot better if you’re sitting down’.

Blogging Barbados: Blinded by Love

A quick snap from my morning walk to the QE.

‘If you don’t lose weight, you’re going to go blind.’

When I was little, one of my biggest fears was to go blind. I could never imagine anything worse than waking up one day to a world of murky darkness that would be all you would ever know.

One of the women I saw in clinic today had had several issues with her health over the past few years. She was very overweight, probably above twenty stone. She had diabetes (type two), a disorder that causes you to be unable to control the amount of sugar in your blood. We need sugar to live, but when too much of it is present in the blood (hyperglycaemia), it can damage blood vessels.

My examination revealed that this lady’s sight had diminished significantly. She was all but blind in one eye and the other was also affected. Learning that she had diabetes, I presumed that she had a disease called diabetic retinopathy. This is where that damaging sugar we mentioned hurts the small vessels that supply the back of your eye, causing insult to the retina and diminished sight.

However, I also found that she had a problem with one of her pupils – a relative afferent pupillary defect (RAPD). This is basically where one pupil dilates inappropriately when you swing a torch between the two, and it is a sign of damage to the optic nerve of the affected eye. One cause of such damage is glaucoma – a disease where the pressure in the eye increases, injuring the optic nerve.

In keeping with most of my time at medical school, all of these guesses were wrong. My consultant explained that this lady has a condition that we actually know very little about, called idiopathic intracranial hypertension. This is where the pressure around the brain is increased, without an obvious cause like a brain tumour (idiopathic is doctor-speak for ‘who knows’). This pressure pushes forward into the eyes and squashes delicate nerves, eventually causing blindness.

IIH is particularly well described in young, overweight Afro-Caribbean women, and is suspected to have something to do with the relationship between adipose (fat) cells and the fluid in the brain. There are medications, but ultimately, the only clear solution is weight loss.

The consultant could not have been plainer in her warning, but the patient left unconvinced. Afterwards, they explained that the attitude of men in the Caribbean towards larger women has meant that some of their patients refuse to cooperate for fear of being less attractive to their partners. One patient, despite being blind in one eye from her weight, maintained a massively popular Instagram account for plus-size modelling.

It just goes to show you always need to keep yourself aware of the local culture. You never know what you might find out.