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.

Blogging Barbados: Getting An Eyeful

Ophthalmology is a field of medicine that treats diseases of the eye. It kind of feels to me like the red-headed stepchild of medical school. I think we’ve had about two days worth of teaching in it over the past four years.

I’m not really sure why this is, but in any case, it’s an area I haven’t got much experience with. Previously any encounter where I didn’t bump into the patient’s head with my ophthalmoscope was a win. In the run up to coming here though, I wanted to up my game. So I hit the books (i.e. ‘Wikipedia’).

Well, at least I thought I did. Today’s seminar definitely revealed some gaps (chasms?) in my knowledge. The teaching was refreshingly simple. No textbooks, slides or handouts. Just a group of about five students getting quizzed by a consultant. This was occasionally the case back in the UK, but not quite as much as I would like.

After this I watched the busy clinic unfold, and saw some really interesting cases. The Caribbean population is at an increased risk of certain eye diseases because of the strong sunlight – one of them being cataract. This is where the lens in your eye gets cloudy and makes it difficult to see. In the UK, these are dealt with fairly quickly, but here, there is a substantial backlog. Prescriptions too are not so easy for patients to collect. I had never really thought about having to wonder if a patient could go away and actually take their treatment once it had been decided what they needed.

Other than that I have discovered the hospital canteen to be wonderfully cheap, cheerful and chicken-ful and am considering moving in there. No beaching today but we are making strides planning out what to get up to next. We might even hire a car if the price is right to have a proper look at the rest of this sunny little island.

Blogging Barbados: Queen Elizabeth Hospital

The main eye care centre of the Queen Elizabeth Hospital

I feel familiar with hospitals. You go to different wards, clinics and operating theatres, but after a while they blur. Stepping into the Queen Elizabeth Hospital, Bridgetown, I felt like I was starting medical school again.

We toured round robust corridors lined end to end with patients. We were taken around our departments, the student common room, and last but certainly not least, the canteen. The Caribbean breeze was unobstructed thanks to huge balcony stretches. I even saw an actual white-coated doctor (!).

Familiar, but fascinatingly different. It made me actually think about what I was seeing. I feel like I’m more switched on than I am on placement in the UK, where it is easy to drift into your own world. Wandering through this new, bustling labyrinth has brought me into the here and now.

Our official placements start tomorrow – today was a day for admin only. My first session will be a seminar on the anatomy and physiology of the eye, on rotation with five University of West Indies medical students. I’m really excited to meet them, as it is hard not to feel a little isolated here. Community is at least as important at medical school as anything you’ll get out of a textbook.

Blogging Barbados: Burgers on the Beach

Barbados seemed small from the plane window. Lying on Browne’s Beach, having trekked through the urban green of Bridgetown (a beautiful sprawl of bleached brick, dotted with exotic trees, geckos and chickens), Barbados seems big.

The overcast sky that greeted me yesterday has grown into a blaze that I am familiar with only through pictures. I think my brain is half convinced I’m in a television advert. I’ve just been served a delicious jerk chicken burger with chips as I watch the waves roll in. I really hope this is real and not in fact in a heatstroke-induced coma.

Whether this is indeed real life or I am en route to the hospital earlier than expected, I am very happy. I feel thoroughly welcomed to the Caribbean. My to-do list has been bulging over the past few months as I sorted out my accommodation, vaccinations, fights and the like but it all seems to have paid off.

All that’s left is to learn a little about sight-saving as well as sight-seeing…

Blogging Barbados: Where Am I?

Enjoying some sleep-deprived euphoria at Gatwick airport.

I am sat studying a little map on the seat in front. A cartoon plane is overlapping the first ‘C’ of ‘ATLANTIC OCEAN’. We are at an altitude of 12,000 feet.

I had no particular intention of blogging my travels to the Caribbean. I had to ask the lady next to me for help just to fill out my immigration form. Having tried and failed to get into a comfortable slump for sleeping however, I have thought again.

I am somewhat poorly traveled (read: I clutch my passport like some sort of holy scripture) and it was partly due to this that I decided to push the boat out for my medical elective. This is where medical students organise a holiday in the sun, briefly punctuated by wandering into a hospital with a forlorn, lost look and a sign-off form.

Jokes aside, electives are an important way to learn something about a health care system other than your own, and it’s a privilege you’ll only get once in a medical career. It’s for this reason (well, that and a good talking to from my vastly more motivated girlfriend) that I abandoned my plan to stay in Newcastle. I emailed probably about 20% of Earth’s hospitals, scouring for any that would give the North East a break and let me wander aimlessly round their wards instead for a month. By a stroke of luck I ended up being offered a placement in ophthalmology in the Caribbean.

So here I am, sat watching our little plane on the television (which is now sitting on ‘TIC’). 2226 miles to go. My name’s Jack, I’m a final year medical student, I’m three centimetres deep in sun cream and I cannot wait!

Why Higher Education?

A little while ago I entered an essay competition which asked students to explain why they love university. Unfortunately I didn’t win, but in case anyone fancies a read, here’s what I wrote.

Don’t forget to check out the winning entries on the link, too!

I normally get into some interesting conversations about how I ended up studying medicine. Before coming to Durham University to start my training as a doctor, I had in fact graduated with a Bachelor’s degree in creative writing and English literature. Medical school certainly wasn’t something I had in mind from an early age.

So why change? I made the jump after a lot of soul searching. I’d always had an interest, but I felt I’d never have a hope of getting in. During my first degree, however, I happily stumbled across widening access routes such as the National Extension College. Through them, I studied biology at home – sieving pineapple enzymes through nylon tights and measuring broad bean roots in the airing cupboard. Age and past qualifications have never been less of a barrier to university.

Now, having finished my first year at medical school, I constantly think about how lucky I am to be here, and how much I enjoy the subject. What makes me love learning medicine is that it blends science and art. I can jump from heart valves to ethical principles in the space of an afternoon. It also has huge personal satisfaction: the reward of one day helping people.

I was drawn to Durham for its focus on developing medical students as individuals – mainly by letting us loose in the local community. This year, I’ve been on placement volunteering at a primary school in a deprived area, and performed house visits to a family to explore the arrival of a new baby. Higher education throws you into new situations like these and lets you grow. It also gives you huge independence. You manage your education, and if you have a question, you have top people around to help. If nobody knows the answer, you can even find out yourself. A conversation with a tutor last term ended up with me putting forward a research proposal!

Could I have done all this without university? Unlikely. To develop and learn, you need to interact with people – and a university is, at the end of the day, a community. Studying for a degree puts you in a melting pot of different lifestyles, outlooks and beliefs. Sat beside me in lectures, there’s an ex-banker, an ex-estate agent, postgraduates and foundation entry students, as well as traditional school-leavers. This diversity, strengthened through societies, clubs and tutorials, enriches learning by making you consider different viewpoints.

Does the degree subject matter? Having experienced both the arts and the sciences, I think both cultivate you as a person. Whether you study sonnets or spines, all degrees are alike in that they plunge you into a culture of like-minded people who will help you enjoy learning. There’s only one thing you need to bring: a genuine interest in your subject.

The take-home message from me is not to worry about barriers, because there are none. As the late Alan Whicker said: ‘find something that excites you and follow it with passion’.