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NOTES FROM THE EDITOR 1

EDITORIAL 2Alternative therapies-how silent we keep!

Medical Matters: QEH BOARD and BAMP

COMMENTARy

New anti-doping section of the BNDF 4

- Dr. Colin Alert

Medical Terminology 5

- Dr. Carlos Chase

Reducing Fatigue-induced errors in Junior Doctors 5

- Dr. Joseph Herbert

CLINICAL ARTICLES

Chronic psychosocial stress and ill-health 6

- Dr. Cindy Flower

Ocular Burns, Chemical 8

- Dr. Trevor Drakes

SPECIAL ARTICLES

Electronic Medical Records (EMH) 11

- Mr. A.R. Edghill

Update on the Barbados National Registry 12for Chronic Noncommunicable Diseases (BNR)

-AMC Rose

REvIEw ARTICLE 14The Changing spectrum of asthma management.

- Dr. Joseph R.K. Butchey

CME ARTICLES / CLINICAL GUIDELINES

Guidelines for transfusion of blood and blood 16

components. - Dr. Emanuel Fakunle

The Menopause - a Discussion 17

CITATION: Dr. Ermine Belle 18

- Dr. Carol Jacobs

NEwS ITEMS AND NOTICES 19

FACULTy OF MEDICAL SCIENCES REPORT 20

- Professor Mike Branday

CERTIFyING THE ELDERLy TO DRIvE 20

- Dr. Michael Hoyos

MEDICAL STUDENT vIEwS

MNI Research Externship Experience 23

- Brittany Carter, Isha Emmanuel, Nicole Simpson

HISTORy OF MEDICINE

The 1854 cholera epidemic in Barbados 24

- Dr. Cheriann Catwell

C O N T E N T SNotes From The Editor

The new BAMP Bulletin will be published quarterly – January, April, July and

October. Special “theme” issues are being considered, as well as the possibility of

both on-line and print publication. The journal has both an Editorial Committee,

chaired by Dr. Ermine Belle, Public Relations Officer of the BAMP Council, and

an Advisory Board of distinguished professionals.

Like most professional journals the BAMP Bulletin evolved from the modest

beginnings of a typewritten newsletter. Its evolution, under quite a number of

editors, led to a consistent 32 page journal, with a variety of articles, but falling

short eventually of attracting a consistent flow of quality clinical, research and

continuing medical education submissions. After an insidious “decline” in health

and vigour, it almost succumbed after its last slender effort in March 2009!

Fortunately, it was discovered that it was not in fact dead, but merely in coma,

and the Council agreed a few months ago to separate the role of Public Relations

Officer and Editor, so that continuity could be achieved and a stronger team effort

created, with the appointment of an Editor, while the PRO assumed the Chair of

the Editorial Committee. The result has been a (w)holistic approach to the care of

the patient, a vigorous response from members, and a healthy result ... but we ask

you, the members and readers to judge, and give us your views, suggestions

and contributions.

Submission of articles is invited under the many headings seen in the

CONTENTS of this issue. Note the distinction between Editorials, which reflect

broad opinion, and which will be seen and may be the joint efforts of, or vetted by,

members of Council before publication, and Commentary articles, individual

opinion pieces on topical issues. We are particularly pleased with the variety of

Commentary pieces, and of Clinical, Special and CME articles. Updates on key

clinical problems of stress and asthma are well presented, and an excellent article

on keeping electronic medical records by Mr. Arthur Edghill, submitted before the

journal’s collapse, appears at last.

Citations, Special Lectures and various reports will be a regular feature, and this

issue includes the inspiring citation for Dr. Belle by Dr. Carol Jacobs. Along with

a report from the new Dean of the Faculty of Medical Sciences, Professor Mike

Branday, is an excellent report on the Externship Experience of third year medical

students at the Montreal Neurological Institute (MNI) at McGill – an exciting new

collaboration. We also invite Personal Views, and letters to the Editor.

Finally, we have an excellent essay on the 1854 cholera epidemic in Barbados, by

Dr. Cheriann Catwell, intern at the QEH. This was a prize winning essay written

during Dr. Catwell’s Humanities clerkship, and is both well written and a model of

good student research in the various archives, libraries and other sources.It’s

particularly appropriate for us to read at this time, not just for the extraordinary

picture painted of a massively destructive epidemic in ghastly social conditions

with minimal health care, but for the relevance to the current epidemic in Haiti.

The scourge of typhoid fever was practically eliminated from CARICOM

countries, yet reared its head again in Western Jamaica recently. Modern air travel

has created a global village, and given the multiple risk scenarios in the Caribbean,

from sloppy practices and facilities of many service providers, including some food

handling situations, to the absence of proper hygienic facilities in our small planes

and the poor washroom facilities everywhere, including airports, we need greatly

heightened public health vigilance and health promotion to prevent spread

of cholera.

The Editor’s final appeal: please submit your articles. They will be peer reviewed

and hopefully published, so please practise “best practice” – share, consult, review

and re-write, to ensure the highest standards. Let’s make the BAMP bulletin a beacon

of light, continuing education, highest quality professional practice, and

entertainment (including medical humour, of which there’s a great deal about!)

BAMP Bulletin – January/February 2011

B A M P 2 0 1 1

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E D I T O R I A L

B A M P 2 0 1 1

Editorial Committee:

Dr. Ermine Belle (Chairman)

Professor Henry Fraser (Editor)

Professor Anne St. John

Professor George Nicholson

Dr. Ingrid Durant

Dr. Maisha Emmanuel

Dr. Joseph Herbert

Advisory Board

Professor Mike Branday

Professor Ian Hambleton

Professor Trevor Hassell

Dr. Carol Jacobs

Professor Patsy Prussia

Professor Nigel Unwin

Professor the Hon. E.R.Walrond

Alternative Therapies -

How Silent we Keep!

The day to day practice of medicine increasingly requires that

physicians and their professional associations turn their attention

to issues that have a bearing on the health of patients and

populations. Although aware of an increasing population of

alternate practitioners and consumers of their products, there has

been little response to date. But as physicians we have a unique

opportunity, AND OBLIGATION, to engage and lead the way.

The growing trend toward alternate therapies and services poses

a predicament for physicians: how to responsibly advise patients

who use or seek alternative therapies in the face of inconclusive

or no evidence about their safety and effectiveness. Yet some

physicians themselves appear to act solely on the lure of financial

gain to engage in such practices with little or no regard for the

confusion and conflict this can create, as patients demand

treatments that may not be appropriate or effective, but may even

be damaging.

This practice is not without risk. Questions of professional

liability are valid. Elsewhere, physicians have been prosecuted

for malpractice when they have personally delivered alternative

treatments.

The other extreme involves the risk of not asking about the use

of alternative therapies known to be dangerous; it is the

physician's professional obligation to be aware of and advise

patients who are using therapies with potential or documented

toxicity, including many herbal preparations, dietary regimens

and supplements, medicinal agents delivered by injection such as

anabolic steroids, and certain forms of spinal manipulation.

Patients who seek alternative medical treatments are not

alternative patients! They must be accorded the same ethics and-

standard of treatment as those seeking conventional, modern,

evidence-based medicine. As more patients use over-the-counter herbs,

botanicals, and supplements, physicians must address the challenge of

discussing such therapies with them - if only to safeguard their health.

Undoubtedly, talking with patients about alternative therapies requires

additional knowledge, skills and time. Ultimately, the patient will have

to assume more responsibility for outcomes in making choices that are

not evidence-based and may be harmful.

As a profession, it’s time to reaffirm our role as trusted advisors.

Perhaps in so doing, we may be able to salvage the societal perception

of doctors as the real healers. As a professional organization, BAMP

has been silent for too long on this burgeoning issue. The question is:

do we have the guts, grit and moxie?

To all members, colleagues in the health professions, patients and our

wider public, best wishes for a happy, healthy and fulfilling 2011.

Medical Matters:BAMP and the QEH Board

The glory days of the QEH are almost as nostalgic as the memories

of the days of a lively youth to the elderly and infirm! Those around

and within the QEH for several decades will remember with pride

the era of the late eighties, when our hospital was on a par with the

University Hospital of the West Indies. It had finally acquired a CAT

scanner, it had a vigorous cardiology service and a new open heart

programme, an excellent dialysis unit, a gastroenterology service,

respiratory unit and so on. Referrals came from all over the OECS.

It was the era when Sir Branford Taitt was Minister of Health, Mr.

James Williams the Hospital Director, Professor the Honourable E.R

Walrond the Dean of the Faculty of Medicine, and although there was

no hospital board, there was the impression that the Minister and his

team sought and took expert professional advice.

The problems of administration over the last many years, however,

have been a nightmare for all. In fact the PAHO / WHO had used the

QEH to create two videos on Quality Management in hospitals, about

15 years ago, but just about when they were to be released senior mem-

bers of the management team were sent on special leave and the videos

never saw the light of day. And the establishment of a Board was seen

as the solution to all problems.

Following the political decision of the Government to institute a

Board, the hands of the first Board were immediately tied – the gross

underfunding of the hospital over many years continued during its first

term, with merely a modest loan of 25 million dollars provided to

remedy a shortfall of many, many times that! Furthermore, no

provision was made to manage the transition to a board, creating

numerous problems for the new board. One big problem was that in

the confusion some of the better middle grade staff opted to leave,

while it was “business as usual” in some sectors. Thirdly, there was

confusion as to whether the Board was a policy board or a board of

management.

The subsequently reported litany of events have done little to

assure the patients, the public or the professionals that the

current Board knows what it is about. Major delays in filling top posts,

3

controversial human resource decisions and failure to either seek

or take the advice of experienced professionals within the hospital

appear to predominate, being for the most part, detrimental to the

operations of the QEH and can be termed inexcusable. Likewise,

we wonder that more than half of the lifts remain out of use,

seriously impairing patient care! And the controversial historical

firing recently of top consultants has adversely affected the

confidence and the morale of many staff: firstly Dr. Brian Charles,

a newly appointed Director of Medical Services; then Dr. Cecil

Rambarat, Head of Radiology and the mainstay of that department

for some years; and most recently the suspension of Dr. Richard

Ishmael, our eminent paediatric cardiologist, for using a Queen

Elizabeth Hospital letterhead to write to the Director of Medical

Services of the QEH, and copied to the Minister of Health and the

Chairman of the Medical Council, to both of whom doctors

in the hospital are, in a sense, ultimately answerable, when the

information contained pertained to a hospitalised patient under the

cardiologist’s care!

The QEH is ideally placed to serve Barbadians and the people

of the Eastern Caribbean well. Neglect of its equipment and lack

of development of services and human resources for many years

will not be solved by a prohibitively costly new building, but by

the triad of:

• Sound management;

• Sound, evidence based professional advice, tied to sound vision

for the development of a state of the art teaching hospital; and

• The necessary financial investment to correct the deficiencies

and develop income generating services for the region.

The advances in medical care – both preventive and curative –

over the last 20 - 30 years have been dramatic, and so have been

the aspirations of our people. Contrary to popular political belief,

roads are less important to people than good health care. If the QEH

Board continues along its present path of aggressive confrontation

with senior doctors, or any members of the health care team for

that matter, it will do so at the peril of our patients and experience

further adversity in relation to its own reputation. A case can be put

that the very composition of the Board needs to be reviewed, since

all of the professional representatives of key stakeholder

organisations (BAMP, BNA, UWI), and lay stakeholders (BARP)

were banished!

By the same token, BAMP and the health care professions at the

hospital – doctors, nurses, pharmacists, nutritionists etc. - must,

through their professional organisations and the several commit-

tees, both regulate their own members to ensure best practice (after

all, as the ancient proverb says “one bad sheep spoils the flock”)

and provide the advice and leadership to guide the Board – in the

hope that they will actually entertain dialogue, with the possibility

of taking expert advice - which they have shown little evidence of

doing so far.

Areas that need urgent dialogue between Board, BAMP and

other members of the health care and teaching team are:

• The development of standards of quality care,

• Strengthening of teaching programmes, especially at the post

graduate levels, for nurses and doctors,

• Review of the human resources needed to capitalise on the huge

potential of QEH for medical tourism – an obvious opportunity

for

E D I T O R I A L . . . cont’d

B A M P 2 0 1 1

for both income generation and national service to our neighbours,

and advocated by members of the medical profession for years,

• Best practice in industrial relations.

BAMP accepts its obligation as a professional association to

work assiduously, in collaboration with the QEH Board, the

Ministry of Health, the UWI, other professional associations and

colleagues in the health team, and our patients, to address these

points, and towards the rescue and correction of the several

deficiencies at the QEH.

69th BAMP / UwI May CME and BAMP Annual Banquet

The BAMP / CME for the month of May this

year is the 69th Continuing Medical Education

conference organised by the BAMP / UwI

partnership. The Conference dates are Saturday

May 14th and Sunday May 15th, while the date

for the Annual Banquet is Saturday May 21st – at

the Lloyd Erskine Sandiford Conference Centre -

with cocktails starting at 7:00 pm.

with mandatory CME now coming on stream, we

hope that both the CME conferences, so splendidly

managed by the partnership of BAMP and the

Faculty of Medical Sciences of the UwI for so

many years, and the newly resuscitated Bulletin

will play a major role in providing valuable CME

for members. The Faculty of Medical Sciences

has indicated that it is poised to expand its offerings

to satisfy the needs of the profession.

It is also hoped that the several new initiatives and

the slow but sure turn around in the economy will

all ensure an increase in every kind of professional

activities, greater collegiality, and a splendid

banquet this year.

Registration details and Registration form follow

the notices.

Note the dramatic savings if you pre-register!

N O T I C E

(See pages 21 and 22 for Registration forms)

4

Congratulations to the Barbados Drug Service, and more

particularly the Drug Formulary Committee, for including a new

section in the most recent edition (#28) of the Barbados National

Formulary, 2009 to 2010. This new section, titled “The World

Anti-Doping Code 2009 Prohibited List International Standard”,

highlights drugs available on the Barbados National Formulary that

nonetheless can cause problems if used by our athletes in Regional

and International sporting competition.

As is noted in the introduction, “This information is intended as

a guide for health care professionals and athletes to alert them to the

drugs that may be restricted in and out of competition in some or all

sports. Please note that this is not a complete list of all prohibited

substances but refers only to those drugs found in the Barbados

National Formulary. This list is updated each calendar year and any

queries should be directed to the National Anti-Doping Commission

(NADC) or the relevant sporting organization”.

The table listed in the Formulary thus provides a ready reference

point to local health officials who may need to prescribe or advise

our athletes on appropriate choices of medications (and supplements)

in health and in sickness. It also advises on which medications cannot

be used at all, and which require specific permission prior to their

use by athletes in completion – this is called Therapeutic Use

Exemption, or TUE. There is a specific protocol in place for this.

While there is limited interest and knowledge in Sports and Sports

Medicine by many physicians (and other health officials) here, the

few who do practice sports medicine are challenged to practice

‘international standard’ Sports Medicine in this environment. As an

example, as recently as the Junior Carifta Games during the Easter

weekend 2009, one young Barbadian athlete had to be withdrawn

(or face sanctions if drug testing confirmed the presence of a banned

substance) after it was discovered that he was prescribed a banned

substance by a local physician. Obviously the communication

channel that should have alerted the physician that this was a young

athlete on the verge of representing Barbados in regional competition

did not work, and his choice of medication by the physician did not

take in account certain restrictions imposed on athletes. Further, the

athlete ‘assumed’ (incorrectly) that once a physician had prescribed

it, then he did not need to report it to his management team, nor could

her run afoul of the anti-doping officials.

The problem has been lucidly summarized in an article readily

accessible on the web: Drugs and sports/Introduction (enotes.com).

The following is an abbreviated extract from this article:

Taking performance-enhancing drugs, or “doping,” has a long

history in sport. In 1904, a marathon runner nearly died from a

mixture of brandy and strychnine, a poisonous substance that in

small quantities acts as a stimulant. Amphetamines replaced

strychnine as the stimulant of choice among athletes in the 1930s.

In the 1950s, responding to news that Soviet Union weight lifters

were being given hormones to increase their strength, a physician

nvented a synthetic substitute—anabolic steroids. Anabolic steroids

quickly became popular among athletes seeking greater muscle

growth and strength. From the 1950s through the 1980s, drugs were

part of the sports and athletic programs of the Soviet Union and its

political allies such as East Germany. Many athletes in East

Germany and other countries were given steroids and other drugs,

sometimes without the athletes’ knowledge; the apparent goal for

ndividual countries was to win national glory through victory in

sports. But today, when an Olympic gold medal can mean millions

in endorsement dollars, the pressure has shifted to individual

competitors and team members.

Perhaps the most famous Olympic drug test came after the 100-meter

dash at the 1988 Summer Olympics in Seoul. Canadian/Jamaican

sprinter Ben Johnson set a world record of 9.79 seconds, but had his

gold medal stripped from him when he tested positive for anabolic

steroids. Johnson eventually was banned for life from track and field

competition. But many believe that Johnson was not the only athlete

to abuse drugs. The Chief Medical Officer of the United States

Olympic Committee from 1985 to 1989, concluded that “the only

thing that separated Ben Johnson from a great number of others who

competed in Seoul in a vast variety of sports is simple: He got caught.”

In 2000 the IOC helped establish a new World Anti-Doping Agency

to coordinate international drug testing efforts in preparation for the

2000 Summer Games in Sydney, Australia.

Some argue that drug testing is futile as newer substances are

invented and developed: in part this is the reason why WADA revise

the prohibited list annually. Some banned substances may be taken,

in some cases inadvertently, through common over-the-counter

medications. Moreover, some observers argue that athletes should

have the right to control what goes into their own bodies. Taking

certain drugs to improve one’s athletic performance, in this view,

differs little in principle from the high altitude training, special diets,

and grueling exercise regimens that are commonplace in sports, even

though many people outside athletic circles would find these actions

“unnatural.” People in other professions often take chemical

substances (such as the caffeine in coffee) in order to boost their

performance in their vocations, and ask why athletes should be

treated differently.

Those who believe athletes should be held to a drug-free standard

offer several reasons. Some argue that taking drugs is simply a form

of cheating that should not be allowed. Others argue that drug use

and suspicion of drug use threaten the enjoyment many people

receive from watching athletes compete. Concern for the health of

athletes is another reason many oppose drugs in sports. Many

performance-enhancing drugs pose health risks. Anabolic steroids

are linked with liver and heart disorders, psychiatric disturbances,

and reduced fertility. They also are blamed for masculinizing effects

on women. Stimulants can cause cardiac arrhythmias and increase

blood pressure. EPO has been blamed for sudden deaths through

blood circulatory failure. Extended use of human growth hormone

may cause diabetes, arthritis, or cancer.

Thus the publishing of the 2009 list of Prohibited Substances, and

relating them to drugs available on the Barbados National Formulary,

is a small but important step in helping Barbados (and Barbadian

doctors) produce some elite athletes in the near future.

C O M M E N T A R y

B A M P 2 0 1 1

New “Anti-Doping” Section in National Drug Formulary

Dr. Colin Alert, MBBS, DM, Member, National Anti-Doping Commission)

5

Medical TerminologyDr Carlos A Chase, MBBS, DGO, CLM, DM

The recent emergence of unusual strains of diseases or diseases

closely associated with animals has resulted in a heightened state

of awareness of the value of good health and the importance of

public health.

We have had within the recent past Ebola virus

(chimpanzees/monkeys), Avian (bird) flu, mad cow disease, SARS,

Resistant TB and more recently Influenza A H1N1 (swine flu).

It is interesting how names have changed and the circumstances

under which they have changed. Medical terminology was consid-

ered to be too complicated and difficult for patients. Terminology

needed to be simpler since the public could not relate easily to them

or they were simply politically incorrect.

Thus we had the disappearance of abortion to be replaced with

miscarriage. Instead of retardation we had “restriction” or “chal-

lenged” inserted and now we hear that swine flu is “unfair” to the

pigs since there are bird, swine and human components. The public

should therefore refer to the virus as Influenza A H1N1.

It is interesting to note that this evolving virus did not have any

travel restrictions recommended by the authorities and one wonders

what a level 5 of 6 alert really means and what was the point.

One might conclude that travel restrictions are optional and need

not be applied at any level since at a level 6 (sustained human to

human contact outside of original area) the damage would already

have been done.

If we are going to move forward in our evolution we need to

make up our minds about medical terminology. It is interesting that

no other professional body or group appears to have changed their

terminology to be user friendly following in our footsteps: for ex-

ample, a financial sheet confuses even the experts, and reading a doc-

ument to obtain a loan still seems to need three years of law school

to comprehend.

If we analyse the current Influenza A H1N1 (swine flu) situation,

(and there is recent resurgence in the UK and possibly in Barbados)

we see the continued medical embarrassment of apparently concen-

trating more on a name and less on the entity at hand.

What, if anything, have we achieved by our continuing medical

evolution? Are our public health policies and messages clear? Is the

profession as a whole involved? And has the level of care given by

doctors been improved and have our patients been the better for it?

You decide.

C O M M E N T A R y . . . cont’d

B A M P 2 0 1 1

Reducing Fatigue- Induced Errors in Junior Doctors Dr. Joseph Herbert, MBBS.

Have you ever noticed that working hours are limited in almost

every profession in which a mistake could result in serious harm or

loss of life? Every day countless flights are further delayed because

the crew has exceeded their allowed flight time limits. For the same

reason freight truck drivers are mandated to pull over and rest for

the night. Since completing my internship at the Queen Elizabeth

Hospital (QEH) last year my colleague and I have often wondered

why our junior doctors are an exception. Maybe it is that we place

some strange value on the tradition of the 36 hour shift as if it were

a rite-of-passage. Perhaps we believe that physicians are somehow

immune to the effects of sleep deprivation. Unfortunately I do not

possess such immunity! On several occasions I have answered a

page while on call, only to fall asleep again! While exhausted, I have

made two management errors that continue to haunt me. I have

nodded off while driving home from work at least three times; in

each case I had not slept for more than 36 hours. From my personal

experience, and the experience of colleagues I can only conclude

that this practice is dangerous for both patients and doctors but in

fact there is a rapidly expanding body of evidence to support this

conclusion.

The Harvard Work Hours Health and Safety Group has

demonstrated that residents working 24 hours on call are at

increased risk of sharps injuries, serious medical errors and motor

vehicular accidents on their way home. Compared to residents

working 16 hour shifts, those working overnight calls have twice as

many attentional failures and commit 36% more serious medical

errors . In a meta-analysis conducted on behalf of the Accreditation

Council for Graduate Medical Education (ACGME) Philibert found

a -.986 reduction in physicians’ aggregate cognitive and clinical

performance after 24-36 hours of sleep deprivation .

In response to such findings, many countries have introduced

restrictions, some more drastic than others. Most controversial is the

European Working Time Directive which has limited junior doctors

in the EU to an average of 48 hours per week from 2009. But both

the Royal College of Physicians and Royal College of Surgeons have

expressed their concerns that such a limitation is “undermining

the safe and effective working of the National Health Service” with

patients being handed over more frequently and shifts as short as

4 hours. There was equal worry about its impact on the quality of

training in the UK. This led to a government-commissioned,

independent inquiry into the matter chaired by Prof. Sir John Temple.

The report, published in June 2010, found that high-quality training

can still be achieved in a 48 hour week but not where trainees have

a major role in on-call services, are poorly supervised or have limited

access to learning opportunities.

In the US, the ACGME has limited the number of work-hours to

80 hours weekly for residents. No more than one overnight call every

third day is allowed with maximum shift duration of 30 hours and at

least 10 hours off between shifts. This is not dissimilar to what house

officers and registrars at the Queen Elizabeth Hospital experience

when there is no shortage of staff.

However, as of July 2011 first year residents will be restricted by

Dr. Filibuster was invited to address school boys on the

subject of premarital sex. He was embarrassed to tell his

rather prudish wife, so he said he was going to talk about

sailing. A few days later his wife met the teacher who

remarked"Your husband was great, The boys really

learned a lot."

"Well that does surprise me," said his wife, " because he

hasn't done it very often. The first time he got terribly sick

and vomited, once he lost his hat, and every other time

he's complained non-stop!"

6

Chronic Psychosocial Stress andIll-health – what you and your patientsshould know Cindy Flower MBBS, DMChairperson, National Advisory Committee on Chronic Pain Management

"If you want to help your patients deal with their stress, you're

going to have to learn to handle your own." Dr. Matthew Budd, Behavioral Medicine, Harvard University

Introduction

It has been noted that in modern societies, a high stress load

correlates with an increasing incidence of mood disorders and

chronic illnesses. These chronic illnesses can have staggering

personal and economic costs but fortunately stress is a potentially

modifiable risk factor for disease.

For doctors, understanding stress has personal and professional

benefits, it is the one problem every doctor shares with every patient

and the lessons we learn for ourselves can then be modeled for

our patients.

History of stress

The term ‘stress’ was first used in the 14th century. At that time

the ACGME to a maximum of 16 hours on call. This follows a

recommendation for a 16 hour limit for all residents by the

Institute of Medicine in 2008.

Unfortunately, there are frequently shortages of junior staff in

several departments at the QEH, resulting in average weekly work

hours well in excess of the ACGME standard. It is hoped that these

staff shortages will be a thing of the past with the creation of the new

Faculty of Medical Sciences at Cave Hill, and a logical approach to

human resources needs.

Another area of concern is the chronic sleep deprivation experi-

enced by junior doctors, after a large survey of residents across the

specialties revealed average self-reported nightly sleep durations of

<6 hours . Interestingly, several studies demonstrate that chronic sleep

restriction of this extent results in a decline in performance similar

to that experienced after acute deprivation . In an effort to reduce

chronic fatigue, both the EU and the US also ensure at least 4 days

off per month for their junior doctors. The current staff compliment

and time table structure employed at the QEH does not allow

for such a luxury. In fact, as an intern I and others have had as

little as one full day off every four weeks while working in some

departments.

It is important to acknowledge that further research is necessary

to guide interventions aimed at reducing sleep deprivation without

compromising the quality of patient care and postgraduate training.

Yet, with an international trend towards reduced hours and shorter

shifts, backed by a growing evidence base, I believe that the

stakeholders in Barbados are forced to carefully consider our options,

C O M M E N T A R y . . . cont’d

B A M P 2 0 1 1

despite our relative lack of resources, in order to improve patient care

and reduce risk. Perhaps employing 16-hour on call shifts would be

a tenable alternative to the status quo but careful planning, would be

necessary to avoid the mistakes of the EU.

My fear is that these views will be scorned as the expression of a

poor work ethic by older colleagues, many of whom worked even

more demandin g hours than we do today. I want to make it clear that

this is not an attack on the internship experience at the QEH – I am

most grateful for the countless learning opportunities it has afforded

me. Rather, I hope that this article triggers debate in the same spirit

that drives us to constantly re-evaluate our practices in the interest of

our patients. After all, would you want a sleep-deprived junior doctor

looking after you or your loved ones?

References

1. Lockley et al Effects Of Healthcare Provider Work Hours and

Sleep Deprivation on Safety and Performance, Joint Commission

Journal on Quality and Patient Safety, Volume 33, Supplement 1,

November 2007 , pp. 7-18(12).

2. Philibert, Ingrid Sleep Loss and Performance in Residents and

Non-Physicians: A Meta-Analytic Examination, SLEEP, Vol. 28,

No. 11, 2005.

3. Baldwin et al A National Survey of Residents’ Self-Reported

Work Hours: Thinking Beyond Specialty, Acad Med 78:1154-

1163, 2003.

4. Veasey et al Sleep Loss and Fatigue in Residency Training:

A Reappraisal, JAMA. 2002;288(9):1116-1124.

C L I N I C A L A R T I C L E S

B A M P 2 0 1 1

it was considered synonymous with physical hardship such as famine

and the plague. In the 1920’s Physiologist Walter Cannon researched

the physiological responses to emotional arousal, introducing the

concept of ‘fight or flight’ as an acute adaptive (protective) function

improving energy and concentration.

In the 1950’s Canadian/Hungarian Endocrinologist Hans Selye

recognized the paradox that the physiologic systems activated by

stress can not only protect but also damage the body. He also reported

stress as the response of humans trying to adapt to the challenges of

everyday life and as such may be a chronic process. So what initially

developed as an acute response to deal with transient danger has

evolved into a chronic potentially deleterious process lasting

days/weeks/months/years.

In 1984 Psychologist Richard Lazarus argued that in order for a

psychosocial situation to be stressful, it must first be appraised as

such by the individual. This notion would then provide a

potential preventative approach to stress management, a process

called reframing.

Definition of stress

Stress is most completely defined as the perception of a threat to

one’s physical or psychological well-being with the added perception

that the individual’s responses may be inadequate to cope with it.

7

C L I N I C A L . . . cont’d

B A M P 2 0 1 1

Immune-related disorders

Others (Infertility, preterm birth, Karoshi)

Fowler-Brown et al, Harvard Medical School published in 2009 a

report indicating that for black women, higher levels of psychosocial

stress at baseline predicted higher adjusted percentage increase in

body mass index over a 13-year follow-up. In 2007 a report from the

Karolinska Institutet in Sweden concluded stress from family or work

life may accelerate coronary disease processes in women. Marmot

et al published in the British Medical Journal in 2006 an article on

stress at work being an important risk factor for the metabolic

syndrome. The Whitehall II study in the United Kingdom reported

(2009) that psychosocial stress at work doubles the risk of Type II

diabetes in middle-aged women. Occupational psychosocial stress,

especially jobs with high demand and low autonomy has been liked

to alcohol abuse and depression.

The association between psychosocial stress and chronic pain is

most evident in the sometimes tedious and vexing issue of chronic

lower back pain. In fact backache is now considered a ‘biopsychoso-

cial pain syndrome’ since psychosocial factors play an important role

in its development and persistence.

The association between stress and other medical illnesses is less

clearly defined. It appears that stress may play a role in the unfolding

of autoimmune diseases and there are reports of a possible link with

gonadal dysfunction and preterm births.

Karoshi, a Japanese word for death from overwork is an occupational

sudden death phenomenon linked to extensive overtime hours.

Interventions

Doctors need to focus on wellness - theirs and that of their

patients. Wellness is defined as the mastery of physical and mental

wellbeing and encompasses nutritional interventions, weight control,

fitness, sleep hygiene, stress management and disease management.

Knowledge of these medical issues is important because as the

saying goes when we know better we do better but equally important

is motivation i.e. the personal incentive to do what we know

aught to be done.

Enhancing human motivation and inspiring behavior change

is the basis of what is being called ‘Lifestyle Medicine’ where

physicians are taught coaching skills (listen, support, empower).

Doctors are reminded that behavior change is a self-change

process and our message to persons with lifestyle diseases and stress

should be that self-management is not only important, it is primary.

A lot is written about physician wellness, burnout and increasing

stress among medics triggered by work-life imbalance, a major issue

for many physicians. William Osler warned about this in a lecture to

medical students in 1899 where he described physicians becoming

habitually engrossed in their professions and losing site of “…those

gentler influences which make life worth living”

The details of stress-management and the appropriate solutions

to specific scenarios is beyond the scope of this author’s expertise

however valuable insight can be derived from many sources

including online (www.instituteoflifesytlemedicine.org). With effort

and determination one can confidently mitigate the influence of

psychosocial stress.

Inherent in this definition is the fact that stress is a very subjective

interpretation of stimuli and as such should be amenable to varying

one’s insight and exhibiting a measure of choice and control over

our responses…it’s not what happens to you that really matters but

how you take it.

Causes of stress

The causes of stress are legion. From major life events like

bereavement and divorce to chronic stressors like financial problems,

unrealistic workloads and job dissatisfaction to daily hassles like

traffic jams and poor service. The stress stimulus may also be

predominantly self-inflicted through personal attitudes such as

having unrealistic expectations of others.

How psychosocial stress leads to ill-health

The event or situation which is potentially stressful must first

traverse the individual’s appraisal process before becoming manifest

as perceived stress. The magnitude of perceived stress is then

modified by certain internal factors (personality, beliefs, genetics)

and external factors (social support, societal mores). Differences in

appraisal and the external and internal factors in part explain the

variations in vulnerability to stress.

The final steps towards ill-health involve negative cognitive,

emotional and behavioral responses as well as injurious physiologic

neuroendocrine responses.

Examples of negative coping strategies that contribute to disease

include poor diet/overeating, smoking, drug and alcohol abuse,

late-night TV, promiscuity, excess doctor visits.

The direct neuroendocrine responses that lead to disease are

centered in the hypothalamus and the multiple mechanisms involved

have been defined with increasing clarity.

Modern research has identified one particular neuropeptide

Urocortin-3 which is produced in an area of the hypothalamus

referred to as the perifornical area under the influence of stress.

Urocortin-3 then stimulates terminal fields in 2 other areas of the

hypothalamus, the lateral septum, leading to anxiety symptoms and

the ventromedial hypothalamus influencing food intake, energy

expenditure and metabolism.

Stress-related illnesses

The notion of stress-induced illness is certainly not new. In 1967 a

validated measure for the risk of illness with stress was developed,

this Holmes and Rahe Stress Scale consisted of a list of 43 potentially

stressful events in the past year of an individual’s life and assigned a

numeric value to these. An individual with a total score of over 300

was deemed at risk of illness. Death of a spouse rated highest at 100

units, divorce and job loss scored 73 and 47 units respectively.

A review of the literature reveals an association between stress and

the following conditions

Obesity

Coronary artery disease

Metabolic syndrome

Type 11 diabetes

Alcoholism

Mood disorders/Depression

Chronic pain/somatoform disorders

8

C L I N I C A L . . . cont’d

B A M P 2 0 1 1

Ocular Burns, ChemicalsDr Trevor Drakes, MBBS

Ocular complaints account for approximately 1-6% of visits to

Emergency Departments. The physical and psychological sequelae

of vision loss make it one of the most feared disabilities.

Objectives

On completion of this article you should be able to

1. Perform emergency care on a patient with chemical burns.

2. Grade chemical burns to the eye.

3. Say how manchineel burns to the eye differ from alkali and acid

burns and respond to treatment.

4. Treat patients with CS gas burns to the eye.

5. Advise your patients on preventive measures against chemical

injury to thei r eyes and 1st aid treatment.

Introduction

Chemical injuries to the eye are true ophthalmic emergencies .Serious

damage is the result of injury with strongly acidic or alkaline

compounds .Immediate prolonged irrigation, aggressive early

treatment and close follow-up are essential for healing and visual

rehabilitation. Most burns are accidental in nature with work related

injuries accounting for 60%, while 30% occur in the home.

The remaining 10% are the result of assault. Alkali burns are

more common.

Sources

• Alkali

– Cleaning products (eg, ammonia)

– Fertilizers (eg, ammonia)

– Drain cleaners (eg, lye)

– Cement, plaster, mortar (eg, lime)

– Airbag rupture (eg, sodium hydroxide)

– Fireworks (eg, magnesium hydroxide)

• Acid

– Battery acid (eg, sulfuric acid)

– Bleach (eg, sulfurous acid)

– Glass polish (eg, hydrofluoric; behaves like alkali)

– Vinegar (eg, acetic acid)

– Chromic acid (brown discoloration of conjunctiva)

– Nitric acid (yellow discoloration of conjunctiva)

– Hydrochloric acid

Pathophysiology

The severity of the eye injury is influenced by the type of chemical,

its volume, concentration, duration of contact with the eye, eye

surface involved and the degree of penetration.

Acids dissociate into hydrogen ions and anions. Hydrogen ions cause

Management

Chemical burns to the eye are an ophthalmic emergency. Time should

not be wasted on history and physical examination. This can be done

following initial treatment.

Initial Treatment

• Immediate copious irrigation

• Topical anesthesia should be instilled if available to improve

patient cooperation

• Can use NS, RL…but irrigate at least 20 – 30 min

• Angiocath or irrigating lens can be used

• Lids should be retracted and fornices swabbed for particulate

matter

• Check pH with litmus paper after initial irrigation

Continue irrigating if pH <6.8 or >7.4

(http://www.pubmedcentral.nih.gov/articlerender.fcgi?

artid=1705681- web reference on equipment and technique

for eye irrigation

what Should you Look For?

Following initial treatment the eye should be carefully examined with

reference to the following

• Presence of epithelial defect

• Conjunctiva/ limbal (ischaemia) – Bells phenomenon

• Corneal clarity

• Inflammation

• ↑ IOP

• Cloudy lens suggests intraocular penetration

Fig 1. Grade 4 Chemical Burn

surface damage while anions cause protein denaturation, precipitation

and coagulation which forms a barrier to ocular penetration by acidic

compounds.

Alkaline substances dissociate into hydroxyl ions and cations.

Hydroxyl ions saponify fatty acids in cell membranes while cations

interact with collagen and glycosaminoglycans in the stroma.

The result is deeper penetration of the cornea and anterior segment.

In general alkali burns are more severe .

9

Grading Chemical Burns

C L I N I C A L . . . cont’d

B A M P 2 0 1 1

Fig 2. Grade 2 Chemical Burn

Fig 3. Grade 4 Chemical Burn

Manchineel Burns

Patients with manchineel burns usually present with involvement

of both eyes. Symptoms and signs include severe pain, severe

conjunctivitis and large epithelial defects. Limbal ischaemia, stromal

thinning and intraocular inflammation are rare. Treatment includes

prompt lavage, topical cycloplegic drops and topical antibiotics.

All patients recover.

Fig 4. Patient with manchineel burns to face and eyes

CS (Tear Gas) Burns

CS gas (o-chlorobenzylidenemalonitrile) is one of the components

of tear gas. Some contain a second chemical 1-chloroacetophenone.

The effects of CS gas on the eye are usually short lived however

chloroacetophenone’s (CN) effects may last for 3 days. CN is found

in mace but may also exist in powdered form. As a result its

effects on the eye may be both chemical and mechanical.

Unlike burns caused by alkalis and acids the eye in cs burns

should be decontaminated by blowing dry air across them. If injury

is secondary to use of the powdered form then the eye should be

irrigated with cold normal saline followed by removal of embedded

particles. Contaminated clothing should be removed and placed in

sealed plastic bags.

10

Fig 5. Grade 4 Chemical Burn

• Cataracts

• Retinal or globe injury (penetration)

Patient Education

• Always wear protective eyewear when handling hazardous

chemicals

• Keep all dangerous chemicals away from children

Conclusion

Chemical burns to the eye are true ophthalmic emergencies. Prompt

initial treatment followed by aggressive early treatment and close

follow-up are necessary for healing and visual rehabilitation.

References

1. Jack J. Kanski .Clinical Ophthalmology A Systematic Approach.

2. John F Pitts, Nigel H Barker, D Clive Gibbons, Jeffrey L Lay.

Manchineel Keratoconjunctivitis. British Journal of

Ophthalmology 1993;77:284-288

3. Sue Stevens. Ophthalmic Practice. Community Eye Health Oct

2005;18(55):109-110

4. H. Wheeler and V. Murray. Treating CS gas injuries to the eye.

Poisons centre will monitor cases. BMJ. 1995 September 30;

311(7009): 871.

C L I N I C A L . . . cont’d

B A M P 2 0 1 1

Treatment

Following initial treatment patients should be referred to an

ophthalmologist where treatment is both medical and surgical.

Medical Treatment

• Mild burns- topical steroids, cycloplegics and antibiotics

• Severe burns – rx to decrease inflammation, promote epithelial

healing and prevent corneal ulceration

• Topical steroids to decrease inflammation and neutrophil

infiltration

• Ascorbic acid to promote collagen synthesis

• Citric acid to reduce inflammatory response and inhibit

collagenase

• Tetracyclines – collagenase inhibitors, inhibit neutrophil activity,

decrease ulceration

Surgical Treatment

The aims of surgical treatment are as follows

• To promote ocular surface healing

• Prevent infection

• Visual rehabilitation

• IOP control

Procedures aimed at promoting ocular surface healing

– Debriding necrotic tissue

– Temporary amniotic membrane patching

– Limbal stem cell transplant

– Cultivated corneal epithelial stem cell sheet transplantation

– Symblepharon lysis-rodding

Visual Rehabilitation

– Corneal grafting

– Keratoprosthesis

Glaucoma surgery

Complications

• Corneal scarring and neovascularization

• Adhesion of lids to globe (symblepharon)

• Glaucoma

Five third year medical students from the new Phase I programme

at the UWI, Cave Hill campus have had papers selected for poster

presentation at the upcoming Caribbean Health Research Council

(CHRC) Scientific Conference 2011 in Guyana. These students

conducted research on topical areas such as oral and

cardiovascular health among UWI students and staff:

Tricia Boyce: Prevalence of Obesity Among Staff at the

University of the West Indies, Cave Hill Campus: Gender,

Age and Diet.

Rojelle Lezama: Comparing the 10 Year Cardiovascular Risk in

Professional Versus Ancillary Staff of UWI, Cave Hill.

Alexis Lowe: The Association between the Prevalence of

Hypertension in Medical Students in Barbados and Waist-to-Hip

Ratio (WHR), Waist Circumference (WC), and Family History

of Hypertension.

Sanita Belgrave - Oral Health & Dental Adherence Among

Medical Students at the University of West Indies, Cave Hill

Campus & the Queen Elizabeth Hospital.

Renikko Alleyne - The Prevalence of overweight, obesity,

pre-hypertension, hypertension and the association between Body

Mass Index and blood pressure in medical students in Barbados.

These research projects were supervised and assessed in the third

year course, Understanding Research, coordinated by Drs. Alafia

Samuels and Damian Cohall.

Medical Student Research accepted for CHRC Conference

11

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B A M P 2 0 1 1

Electronic Medical Records (EMR)Mr. Arthur R. Edghill C.B.E., F.R.C.S., Ed., F.C.C.S.

Definition

The EMR is the legal record, created in electronic form, which

includes a secured file of patient demographics, patient history,

patient clinical notes however compiled, billing and payment

information and all other information necessary to have a complete

patient profile. Indeed, it is the legal record of what happened to

that patient during their encounter with a care giver or care

delivery organization.

Electronic record keeping has been mooted for years. It will

certainly get a major boost given the $ 19 billion earmarked for

paperless systems in the new US stimulus package. Statistics show

that in the US only about 20-40% of physicians use some type of

full or partial EMR system. No statistics exist for Barbados but usage

of EMR is not widespread.

Benefits of EMR

1) Elimination of paper charts and the cost associated with them.

We are all too familiar with paper records, filing cabinets and the

ever increasing demand for additional space just to store these

records. The efficiencies created by simply typing a few identifying

keystrokes to retrieve a patient's electronic record, as opposed to

staring at thousands of file folders, filing, re-filing and often misfiling

them, saves a doctor's practice or a hospital many thousands of

dollars, for in any business, time equals money. Contrast this with

the storage and retrieval of Electronic Medical Records; a computer

hard drive, a USB pen drive or a DVD Rom disc are effective means

of storing a lifetime of medical records. Though I know of no

Caribbean study, in the US it is estimated that the creation, tracking,

storage and maintenance of paper records cost $8 US per record per

year. An electronic record stored on computers or other data

storagedevices, costs on average about $2. Savings arise not only

from the cost of paper and file folders, but the cost of filing cabinets

and space required, as well as time and labour cost.

2) Precise & Legible records.

Electronic dada entry to a computer generally requires keyboarding

skills, which few of us possess. Entry of data then presents a

challenge; indeed it is my experience that it represents the greatest

deterrent to the change-over from paper records to electronic records.

But help is readily available.

The most widely used alternative methods of data entry into EMR

are as follows:-

• Template - the physician uses a general template pre-fabricated

for the type of case at that moment, making it specific through

use of forms, pick-lists, check-boxes and free-text boxes. I have

found templates of particular value in the creation of operative

notes, when stored descriptive texts for various operative

procedures may be retrieved at a key stroke and edited as

necessary. Needless to say the operative notes are now concise

and legible by all.

• Voice recognition -the physician dictates into a computer voice

recognition device that enters the data directly into a free-text area

of the EMR. MS Word includes speech recognition and I have

found it to be adequate after appropriate training. Other speech

recognition software is available as stand alone applications.

• Transcription - the physician dictates into a recording device,

which is then sent to a transcriptionist or to one’s office receptionist

with typing skills, for entry into the EMR, usually into free text

areas.

• Scanning– Certain documents such as Investigation records and

pictures may readily be scanned to free text areas in the EMR.

Scanning doctor’s notes has obvious disadvantages but may be

the only suitable method of entering old records.

• Concept processing - based on artificial intelligence technology

and Boolean logic, Concept Processing attempts to mirror the

mind of each physician by recalling elements from the EMR of

past cases that are the same or similar to the case being seen at that

moment. A Concept Processor brings forward the closest previous

encounter in relation to the one being seen, putting that case in

front of the physician for fine-tuning.

Most major EMR systems have built in templates that allow

physicians & or transcriptionists to add notes more efficiently but

just as important, more accurately and more legibly. You may not

however be able to entirely eliminate the need for transcription or

real time keyboarding.

3) Efficiency and Improved patient care.

With patient records at your fingertips the physician is well placed

to provide safe and efficient patient care. The EMR stores all relevant

clinical data and does not depend of the patient recalling historical

data including drugs and previous surgeries, investigations etc. And

when the EMR is shared, all that is often necessary for any attending

physician to access the complete record is to enquire of the name

and DOB of the patient. I have selected four areas to demonstrate

efficiency and improved patient care.

• Patient scheduler or electronic diary. All patients are entered in the

diary that stores patient name, scheduled date and time and

reason for visit. At any time the scheduler may be amended.

But more importantly it may be readily searched. How often does

the receptionist receive requests from patients who have either

forgotten the date and or time of their next appointment and then

spends valuable time searching the paper diary for the

information. With the EMR the answer is a few keystrokes away.

• Prescriptions. With pre –entered drug and dispensing data,

prescriptions can be readily generated, printed, stored and recalled.

The printed version is precise and legible, without old fashioned

symbols, thereby eliminating prescribing errors. Repeat

prescriptions may be generated by the practice nurse, only

requiring the physician’s overview and signature.

• Patient accounts. With pre–entered service charges, all billing to

individual patients or to third party payors is accurate and created

in real time. Receipts are generated and printed in real time and

daily computer generated reports allow for accurate bookkeeping.

More importantly, should the account be subject to questioning

at anytime after its creation, recall is automatic without the need

for a search through a myriad of paper documents.

• Reports. Most EMR systems include a reporting module that

allows for an analysis of your patient’s data. One such report of

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S P E C I A L . . . cont’d

B A M P 2 0 1 1

particular relevance to surgeons is a Blood Group report.

Taken further, analyzing practice data allows for improved patient

services and outcomes.

• Alteration of Records. Alteration of electronic records is time

barred; changes made after a specified period, usually 24 hours,

are reflected as an addendum. The original record remains

unchanged. The legal implications are obvious.

4) Sharing and privacy of EMR.

Patients generally have little or no say in what we as doctors do with

their sensitive records, but they do expect us to respect the privacy

of such. Paper records are particularly vulnerable in this respect.

EMR, though easily shared are safeguarded by a variety of measures.

In the typical physician’s office, computers are linked to each other

over a Network which may be wired or wireless. All who are

required to access data are set up as Users. Each user must have a

specific user-name and password and will be given specific

permissions. Thus a Receptionist may have full access to enter

Appointments, Demographic data and Accounting data but will have

no permission to view, update or delete clinical data. Users no longer

associated with a practice should be removed. It should be manda-

tory that User passwords be changed at preset intervals.

Data stored on the server must be backed up to one or more

mediums, for computers do fail and with such failure may come the

loss of all data. It is here that the System administrator must make

certain decisions. In my case I made a backup to a second hard drive

on the Server. A second backup was made to an external hard drive

that could be taken off site and finally a third backup was made to a

USB pen drive from which data could be readily restored.

But no system of record keeping is without security risks and that

clearly includes paper records whose only security from prying eyes

is the key to the filing cabinet, if locked! In the setting of EMR just

described, records are generally secure and are more at the mercy of

how you, the physician, handles them and less at risk from hackers

and other violators. Attaching your pen drive containing your

EMR’s to your key chain is clearly not recommended.

However, it is when data is transmitted over the Internet and stored

in cyberspace that security becomes more of a concern. In the US

the Health Information Portability Accountability Act (HIPAA)

determines how health information may be shared electronically.

Though it is reported to provide good opportunities for sharing

such information, it also creates road blocks and leads to confusion.

It can be a major problem if a loved one or a health care proxy wants

access to a record.

And yet access of records over the Internet has many significant ad-

vantages. Patient data may be reviewed over the Internet by a variety

of devices including the mobile phone. A family physician referring

a patient to a Specialist may, through suitable access, transmit the

relevant data ahead of the visit to the Specialist, all making for effi-

cient patient care. Likewise, the report of the Specialist may be re-

turned to the referring physician over the internet.

Needless to say patients may readily acquire a copy of their entire

clinical record, either as a hard copy or as an electronic record. To

provide such a copy with paper records is often a monumental task

particularly for long standing patients. With EMR it is a breeze. This

becomes of real significance when a doctor closes his office, retires

or even dies.

Requirements for EMR

The cost of generating EMR will clearly vary depending on the level

of computerization that already exists in your office. Spend you

money on a fast processor, loads of Ram, and a widescreen flat panel

monitor. You and your staff will spend much time gazing at the mon-

itor and the bigger the better; flat screens occupy far less room on

your desk and are now relatively cheap. A printer attached via a print

server will be available to all computers on the network. Make pro-

vision for data backup and restore, preferably with an external hard

drive that may be taken off site. All of your electronic equipment

should be protected by a surge suppressor and a UPS.

The EMR software you select however will need to be evaluated

closely to ensure that it works for you rather than you working for it!

It must first and foremost be user friendly; screens cluttered with data

fields all requiring an entry can be very intimidating. Built in help

screens are useful. Whatever software you choose there will be a

learning curve and you will need to dedicate time for training of

yourself and your employees. Demo software should be available

so that you may examine the functionality and suitability for your

individual practice. No two practices are alike and physicians are

very individualistic; no software will be perfect for every practice

and customization will be required. Software that does not allow for

customization will likely frustrate the user and will be abandoned.

In the setting of Barbados, the solo practitioner starting from scratch

will likely spend $ 8000.00 to $ 10,000.00 to make the change.

Remember that imported computer hardware into Barbados is

duty free. Yearly costs to cover hardware maintenance and repairs

together with software support will likely be about

$ 1500.00. Experience in the USA suggest that the physician will at

first work longer hours as he or she becomes familiar with the

software but that the average practice would pay for the initial and

ongoing EMR costs in 2.5 years. In the Caribbean it may take

somewhat longer

Update on the Barbados National Registry for Chronic Non-communicable Diseases (BNR)Ms AMC Rose, MSc PH, BNR Director, UwI CDRC

World Health Organisation (WHO) projections to 2030 indicate

that, by 2010, the leading global causes of death will be chronic

non-communicable diseases (CNCDs).1 Prevalence of CNCDs

generally increases with age, and four of the top 10 most rapidly

ageing nations are in the region of Latin America and the Caribbean

(LAC). This region now has a greater health burden from CNCDs

than infectious disease: the so-called epidemiological transition.2-4 In Barbados, the transition to chronic disease has reached

epidemic proportions (source: Chief Medical Officer’s Annual

Report 2002-3), with the third-highest mortality from CNCDs in

LAC and rates approaching those in the traditional industrialised

nations. The Port-of-Spain Declaration, arising from a Caribbean

Heads-of-Government meeting in September 2007, gave the clear

commitment of regional governments to combat the morbidity and

mortality burden from CNCDs.5 Earlier that year in Barbados,

the National Chronic Non-Communicable Disease Commission was

13

S P E C I A L . . . cont’d

B A M P 2 0 1 1

created to overview and support preventative and therapeuticstrategies against CNCDs. Through this commission, and withfunding from the European Development Fund, the Chronic DiseaseResearch Centre of the University of the West Indies was contractedto implement and manage the Barbados National Registry forChronic Non-Communicable Disease (BNR), comprising threechronic diseases: stroke, acute myocardial infarction (AMI)and cancer.

Surveillance is the provision of information for action throughongoing data collection, collation, analysis and dissemination ofresults. There are two types of surveillance. In sentinel surveillance,key health events are monitored. This may be done through key (or‘sentinel’) sites, e.g. a particular polyclinic to which most people gofor diabetes care, , could be the sentinel site for diabetes surveillance.In this case, there may be just one sentinel site in a country, atwhich information on all of the health events in question (diabetes)are compiled.

Alternatively, the event may itself be the sentinel, e.g. in manycountries a single case of yellow fever triggers the declaration of anoutbreak. In this case, all laboratories testing for yellow fever wouldbe sites for the sentinel surveillance system. Sentinel surveillance ischeap and good at showing trends in disease, although it is liable tobias (as the data may not be representative of the whole population);as a result no incidence data can be calculated. The other type ofsurveillance is population-based. This is representative of thepopulation, so incidence may be calculated, as the data aregeneralisable. However, this type of surveillance is more expensiveto set up and to run, as there will be more sites and resources neededto cover the entire population. The collection of data for surveillancecan be passive, through case reports, or voluntary physician notifi-cation; this is the simple, cheap method, though perhaps unreliable(e.g. diabetes is on the notifiable diseases list in Barbados but is rarelynotified). The alternative is ‘hot pursuit’ of cases, or activesurveillance, in which cases are sought actively by the system; thisis timelier than passive surveillance but uses more resources.

A register is literally a data file of health-related events, compiledfrom different data sources and allowing long-term follow-up ofevents and individuals, including outcome data. A registry is thereforethe system of ongoing registration. A disease surveillance registry isnot the same as a patient management register, which has theobjective of providing a trigger to physician, clinic and/or patientabout upcoming events or needs such as screening, vaccines, etc.The objectives of a surveillance registry will include assessing burdenof disease, monitoring trends, providing information for programmeor service evaluation and supporting policy development.The objectives of the BNR are to collect timely and accurate nationaldata on the occurrence of stroke, AMI, and cancer, in order tocontribute to the prevention, control and treatment of these diseasesin Barbados.

Three registries in one does not mean three times the effort, asthe data sources for the BNR-Heart and BNR-Stroke are broadlysimilar, and all three registries have similar resource needs. There isone data management system covering the BNR, and although theinitial software outlay is high, for the up-to-date software whichprovides bar-coded scannable forms to obviate double data entry, therunning costs are low, particularly as there will be one database forall three registries.

The BNR methodology uses internationally accepted tools and

best practice, and has involved disease specialists in development of

the questionnaires and processes. Data sources were contacted and

ethical approval was obtained from the Institutional Review Board.

All BNR staff are required to sign confidentiality agreements prior

to starting work, and the highest international standards of data

encryption and storage, with a secure database, are utilised to ensure

full confidentiality. Informed written patient (or relative) consent are

required for all interviews. Finally, there are three main committees

to govern the BNR: the Professional Advisory Board, which is

involved with strategy and planning (Chair: Prof Trevor Hassell,

CNCD Commission); the Technical Advisory Committee, which

concerns technical issues and challenges (Chair: Dr Gina Watson,

PAHO); and the Data Sources Group, which covers data source

challenges or other data issues (Chair: Dr Ian Hambleton, CDRC).

The BNR asks the medical community in Barbados to notify each

stroke or acute MI you may diagnose, even if you think the patient

may have been notified before, and to encourage/inform patients to

be part of the registry. To notify, please use either the BNR notification

form (see Appendix) or call the BNR Hotline on 256-4BNR. The

BNR must collect accurate data on every newly diagnosed stroke,

AMI, and cancer patient; every healthcare professional has a potential

role to play, as you are in the frontline, diagnosing the cases.

The BNR is the first national, population-based, combined-disease

registry in the Caribbean. The registry began in July 2008, collecting

information on all stroke events island-wide (BNR – Stroke). After 9

months, 427 notifications had been received, of which 308 were

registered (69%). Of these, most (185; 60%) were female. Survival

to 28 days was approximately 70% for both men and women with

strokes. The pilot for the BNR – Heart (collecting data on all events

of AMI throughout the island) will start in April 2009. The third

component, BNR – Cancer, should be piloted later in the year.

References

1. Mathers CD, Loncar D. Projections of global mortality and

burden of disease from 2002 to 2030. PLoS Med 2006

Nov;3(11):e442

2. Caldwell JC. Population health in transition. Bull World Health

Organ 2001;79(2):159-60.

3. Gwatkin DR, Guillot M, Heuveline P. The burden of disease

among the global poor. Lancet 1999 Aug 14;354(9178):586-9.

4. Omran AR. The epidemiologic transition. A theory of the

epidemiology of population change. Milbank Mem Fund Q

1971 Oct;49(4):509-38.

5. CARICOM Heads of Government. Declaration of Port-of-

Spain: Uniting to Stop the Epidemic of Chronic Non-

communicable Diseases. CARICOM Secretariat 2007

September 15 [cited 2008 Nov 6]

Available from: URL:

http://www.caricom.org/jsp/pres sreleases/pres212_07.jsp

Laughter is the cure for many little ills.

It cures more quickly than the

doctor's tiny pills.

14

R E v I E w A R T I C L E

B A M P 2 0 1 1

The Changing Spectrum of Asthma Management

Dr Joseph. R. K. Butchey, MB. BS, FRCP©, FAAAAI,

(Adjunct Professor of Medicine, University of western Ontario, London, Canada)

This review is based on a paper given at the recent 10th UWI

Medical Alumni Reunion Conference at the Accra Beach Resort

(November 2010)

In Canada as in several other areas worldwide, asthma

management has changed due to new information regarding path

physiology of asthma, the availability of new asthma medications,

human perception and behaviour with regards to chronic diseases

of which asthma is a prominent example.

This disorder is a huge medical problem worldwide and the

following is a snapshot of the various changes which have occurred

in Canada over the last 50 to 60 years. This paper summarizes the

key points in diagnosis and management in individuals six years

of age and older.

A recent WHO estimate indicated that approximately 7% to 10%

of the world population is afflicted with this disorder, with a death

rate of about 250,000 per year. In Canada, it is estimated that 10%

to 15% of the population are affected with this disease (1).

The three main characteristics of asthma are inflammation of

the airways, variable air flow obstruction and hyper responsiveness

of the airways to a variety of stimuli such as infections, exercise,

pollutants and cold air.

Good management of asthma should

start with confirmation of an accurate di-

agnosis by correlating a good and careful

history withobjective measurements of

lung function. The history should

include episodic wheezing, shortness

of breath, chest tightness, coughing,

nocturnal awakenings, emergency room

visits and hospitalizations due to breathing

difficulties. Objective measurements of

lung function should include spirometry

to demonstrate reversibility, peak flow

readings showing variable obstruction,

methacholine, histamine and exercise

challenge tests (2).

The goals of management include

controlling symptoms, maintaining

normal activity levels, maintaining near

normal pulmonary function, preventing

acute episodes of asthma, avoidance of

side effects of asthma medications and

preventing asthma mortality (3) (5).

Once the diagnosis has been con-

firmed, patients should be involved in

their management in order to achieve motivation which in turn will

lead to better adherence and compliance with treatment. Identified

environmental triggers such as dust mites and animal dander should

be avoided, appropriate and correct use of inhalers, with a spacer,

should be taught as this is critical to effectiveness of the inhaler, and

a written action plan should be provided to the patients. This action

0000

plan should include daily preventive management to maintain

control, how to adjust reliever and controller therapy for loss of

control and instruction when to seek urgent medical attention (2).

For mild and occasional symptoms, a fast acting bronchodilator on

demand should be provided for rescue purposes when necessary.

If the need for this fast acting bronchodilator is more than

three times per week, then a daily controller medication viz. an

inhaled steroid should be started. This inhaled steroid can be

increased to a mediumdose or high dose in children six years and

over and in adults (2). A second line treatment at this point would

include a Leukotriene Receptor Antagonist (LTRA) (4). If control is

not achieved, the options then would be to increase the inhaled steroid

in children 6 to 11 or to add a long acting Beta Agonist preparation

in children over 12 and adults.

For more severe and persistent asthma, short courses of oral

prednisolone often provide a good response. Over the last few years,

there have been several studies which have shown the safety and

efficacy of using allergen-specific immunotherapy in children and

adults with rhinitis and asthma. This allows yet another option

in managing this disorder (8). If the courses of Prednisolone are

frequent or the patient becomes steroid dependent, then consideration

should be given to use of an anti-IgE preparation (Xolair) which is

usually administered monthly by the subcutaneous route. It should

be borne in mind, however, that this treatment is quite costly and

should only be used selectively.

This management is nicely summarized in the diagram titled

0000000

References

1. Subbarao P, Mandhane PJ, Sears MR, Asthma: epi demiology, etiology and risk factors. CMAJ 2009. 181(9). 598-604.2. Lougheed MD, Lemiere C, Boulet LP, et al. Canadian Thoracic Society Asthma Management Continuum. Can Respir J 2010;17(1):15-24.3. Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention. Global Initiative for Asthma (GINA); 2007.4. Ducharme FM, Schwartz Z, Kakuma R. Addition of anti-leukotriene agents to inhaled corticosteroids for chronic asthma. Cochrane Database Syst. Rev 2004 ;1:CD003133.5. Lundback B, Dahl R. Assessment of asthma control and its impact on optimal treatment strategy. Allergy 2007:62:611-619.6. Litonjua AA, Weiss ST. Is Vitamin D deficiency to blame for the asthma epidemic. JACI 2007;120:1031-1034.7. Nagel G, Strachan DP, et al. Effect of diet on asthma and allergic sensitization in the International study on Allergies and Asthma in Childhood (ISAAC) phase two Thorax. 2010;65: 516-522.8. Zielen S, Kardos P, Madonni E. Steroid-sparing effects with allergen-specific immunotherapy in children with asthma. A randomized control trial: J Allergy Clin Immunol 2010; 126: 942-949.

15

R E v I E w A R T I C L E . . cont’d

B A M P 2 0 1 1

Asthma Management Continuum (2).

For good asthma control, the bjectives are to reduce day time

symptoms to less than three or four times per week, nocturnal

symptoms to less than once per week, while physical activities should

be normal, exacerbations should be mild and infrequent, there should

be no or infrequent absence from work or school due to asthma,

and need for a fast acting Beta 2 Agonist should be less than four

doses per week.

There have been some recent thoughts and ideas to account for

the increase in asthma and to try and reverse this process. In a paper

in the JACI (November 2007) Litonjua and Weiss wondered whether

Vitamin D deficiency may be to blame for the asthma Epidemic (6).

In Thorax August 2010) Nagel et al wrote an interesting paper sug-

gesting that adherence to a Mediterranean diet may provide some

protection against wheeze and asthma in childhood (7).

In summary, we currently have the tools to achieve good control of

asthma in most cases but compliance and adherence, as in most

chronic diseases, remain challenges. The hope for the future is that

we can achieve this control and curb the current trend in the increase

in asthma prevalence.

Alumni Reunion: 10th Reunion and

Scientific Conference of the

UwI Medical Alumni

Association (UwIMAA)

at the Accra Beach Resort, Barbados –

November 15 - 20, 2010

The 10th Reunion and Scientific Conference at the Accra Beach

Resort in November was a fantastic experience for the 150 overseas

participants and those local alumni who “took time out from

their busy practices”! Those who considered themselves too

busy have no idea what a great experience they missed.

The overwhelming quality of the conference and the whole week’s

social events was beautifully summarised by the message received

by our star alumnus, Sir George Alleyne (Class of '57), Director

Emeritus of the Pan American Health Organisation and UN

Special Envoy for HIV/AIDS, which we publish below.

At the Reunion, Dr. Gerry Groves (Class of ’69) of the Tri-State

Chapter in the USA was elected the new President of the

Association, replacing Dr. Michael Hoyos (Class of '64).

It’s worth noting that the class of ’64 had the highest percentage

of classmates present at the Reunion (10) while the class of ’69

had the largest number (16)! Let every class surpass that at the next

big reunion in Jamaica in two years time ... let everyone who

had such a rewarding and inspiring time here make sure that two

or three classmates come to Jamaica for the next big one.

Letter from Sir George Alleyne toDr. Hoyos, Immediate Past President ofUQIMAA

Dear Mike

I wish to congratulate you and your colleagues on an excellent

reunion. I do not think that there could have been anyone who did

not enjoy it. The scientific presentations were of a very high standard

and the presence of so many persons in the audience on Saturday

morning is a testament to the amount of interest that was generated.

The conference booklet was very well put together and the abstracts

gave a very good indication of what was to be presented. I noted

that a good number of the presentations were made by young

professionals and that augurs very well for us.

I know that you were concerned about the number of attendees, but

I would not worry too much if I were you. There was quality and the

quantity was really not bad. If 10% of the 7000 alumni turned out,

we could not handle them. And then there was the nostalgic/

sentimental part of it which cannot really be measured and I know

that for many of the older folk that is perhaps the most important

part. The spontaneous or last minute party on Saturday was also

lively and Sylvan and I certainly enjoyed it. I could have done without

the skit at the smoker, but that was just a very small pimple on what

was really an excellent reunion.

Thanks for asking me to speak at the banquet and I am glad it went

well. You should feel very satisfied indeed with your chairmanship

and I will do whatever I can to help as Gerry takes over.

Kind regards

Champ (George Alleyne)

UwIMAA REUNION REPORT

16

1) Transfusion of Packed Red Blood Cells (Prbc) (Documentation of clinical and laboratory response to

transfusion of PRBC is recommended within 24 hours after the

transfusion is completed)

The conditions listed below are considered to be reasonable

indications for the use of the following blood component(s) available

at Queen Elizabeth Hospital, Barbados, blood bank.

1) Transfusion of Packed Red Blood Cells (Prbc)

(Documentation of clinical and laboratory response to

transfusion of PRBC is recommended within 24 hours after the

transfusion is completed)

a) Haemorrhagic shock due to surgery, trauma, invasive

procedure, medical conditions (e.g. GI haemorrhage)

b) Active bleeding with blood loss in excess of 20% of the

patient’s calculated blood volume, or blood loss with 20%

decrease in blood pressure and/or 20% increase in heart rate.

c) PRBC transfusion is rarely indicated when the haemoglobin is

above 10 g/dl and it is almost always indicated in patients when

The haemoglobin is below 6 g/dl.

d) The determination of transfusion in patients whose

haemoglobin level is 6 – 10 g/dl should be based on the

patient’s risk of complications due to inadequate oxygen

supply.

e) Symptomatic anaemia with haemoglobin less than 8 g/dl or

angina pectoris/ CNS symptoms with haemoglobin less than

10 g/dl

f) Asymptomatic anaemia with preoperative haemoglobin less than

8 g/dl, AND anticipated surgical blood loss greater than 500 ml.

g) The use of alternative measures to reduce allogenic red cell use

should be considered, including preoperative autologous

donation, intra-operative and post –operative autologous blood

recovery, acute normovolaemic haemodilution, and operative

and pharmacologic measures that reduce blood loss.

Note: In individual patients, end-organ problems may warranttransfusion at higher levels of haemoglobin.

2) Transfusion of Random Donor Platelets or

Plateletapheresis Units(Documentation of clinical and laboratory response to

transfusion of platelets is recommended within 10-60

minutes after the transfusion is completed)

a) Prophylactic Platelet Transfusions (to prevent bleeding in the

patient with Thrombocytopenia)* with platelet count equal to

or less than 10,000 per microliter blood.

b) Platelet transfusions MAY be given to patients who have platelet

counts equal to or less than 50,000 per microliter blood AND

have bleeding due to thrombocytopenia* or platelet

dysfunction.

c) Platelet transfusions MAY be given to patients who have platelet

counts equal to or less than 50,000 per microliter blood AND

Guidelines for Transfusion of Blood and Blood ComponentsDr. Emanuel Fakunle, MBChB, FMCPath, MSc

C M E   / C L I N I C A L   G U I D E L I N E S

B A M P 2 0 1 1

have a potential for bleeding from an invasive procedure such as

surgery, lumbar spinal puncture, etc.

d) Platelet count greater than 100,000 and evidence of

bleeding due to platelet dysfunction not responsive to DDAVP or

cryoprecipitate.

3) Transfusion of Fresh Frozen Plasma

(Documentation of clinical and laboratory response to

transfusion of fresh frozen plasma is recommended within 1

hour after the transfusion is completed)

a) Dilutional coagulopathy (i.e. massive transfusion), active

bleeding, surgery or invasive procedure and at least one of the

following:

• Prothrombin Time (PT) greater than 18 seconds

• Activated Partial Thromboplastin Time (aPTT) greater than 54

seconds

• Specific clotting factor deficiency (< 25% of normal) for which

other safer replacement product is not available.

4) Transfusion of Cryoprecipitate

(Documentation of clinical and laboratory response to

transfusion of cryoprecipitate is recommended within 1 hour

after the transfusion is completed)

a) Bleeding and/or potential for bleeding associated with surgery

or an invasive procedure and at least one of the following:

• Fibrinogen levels less than 115 mg/dl

• Factor XIII deficiency (less than 25% of normal)

• Platelet count greater than 100,000 with evidence of platelet

dysfunction and no response to DDAVP

Note: When in doubt on the type and/or quantity of blood

components necessary to treat your patient, telephone consultation

with the haematology registrars on call is readily available 24 hours

a day by calling the hospital switch board at 436-6450.

Commentary on Transfusion Policy Followed In Barbados

Pre-Transfusion/ Pre Cross-Matching

It is mandatory that blood and blood products should be

prescribed only if less hazardous therapy is likely to be ineffective

and if the benefits of transfusion outweigh its risks.

Ideally, a patient should receive only the blood component that is

required at all times.

Doctors, nurses and technologists have the responsibility to

ensure that samples of blood sent for grouping and cross-matching

are legible, fully and correctly labelled and the recipients are properly

identified before transfusion is started to prevent clerical errors.

When the requested blood is available, the blue request form

will be kept in the blood bank until the blood units are collected or

there is no longer a need for that transfusion at which time the form

will be returned to the ward. The front of the form (1st page) will

have the patients demographic filled out by the clinician and at the

00

17

C M E   / C L I N I C A L   G U I D E L I N E S . . . cont’d

B A M P 2 0 1 1

back (2nd page) the donor unit number(s), blood ABO and Rh (D)

groups of the patient and unit(s), if serological tests were done, and

for how long the unit(s) will be available. The information at the back

of the form must be completed by the technologist.

Pre-Transfusion/ After Cross-Matching

Release of units will only be to authorize medical personnel,

i.e clinicians, nurses, nursing assistants, orderlies. Blood will not be

released to housekeeping, dietary, clerical or other ancillary

personnel. Each unit issued must be signed for by the collector in the

appropriate register.

Accurate identification of the donor unit and the intended recipient

is the responsibility of the collector.

Blood issued for outside facilities will be released to their

authorized personnel by the technologists on duty.

Units of packed cells will be released one unit at a time.

When the released of multiple units are required the following

principles should be strictly adhered to.

1) Blood for more than one patient will not be released to

same person simultaneously.

2) In instances of severe blood loss resulting in the need for

rapid replacement, more than one unit may be released by the

technologist.

3) When more than 2 units of packed cells are required, it is the

responsibility of the blood bank technologist to pack

adequately to assure temperature control.

4) At no time will more than 6 units be released at one time.

5) Blood must never be stored in ward refrigerators.

Before and after transfusion, it is mandatory for the patient’s

temperature, pulse/ respiratory rates and blood pressure to be

recorded on the appropriate chart and any abnormalities should be

reported to the clinician.

The person administering the blood product must enter in the

patient’s notes;

1) The number(s) and blood groups of the units(s) being

transfused.

2) The type of blood component(s).

3) The time of starting and finishing of the transfusion.

4) Sign to indicate that pre-administration checks have been

performed.

Blood components must be transfused through standard blood

filters (170 microns). During the first 15 min the patient should

be observed closely for any adverse reaction and the clinical

condition must be closely monitored during and after the transfusion

for prevention and treatment of any adverse events.

Transfusion of packed cells must be started within 30 min of

removing the unit from the blood bank and must be completed within

3 hours. If kept longer, the transfusion should be stopped and the

remainder discarded. Transfusion of other components apart from

packed cells must be as quickly as possible.

No medication or other intravenous fluids should run

simultaneously with the blood component.

All identification must remain attached to the container during

0000

and after transfusion. The time of completion of transfusion must be

documented at all times.

The sealed blood component bag, along with the information

properly completed on the attached tag must be returned to the

blood bank.

The nurse in charge of the patient must return the transfusion

bag with the attached administration set (without the needle) and all

related forms to the blood bank.

The nurse in charge of the patient and the doctor on call

must institute emergency procedures as directed by the attending

physician.

The doctor on call must send a post reaction EDTA blood

sample to the blood bank immediately.

A transfusion reaction investigation form will be initiated by the

blood bank technologist on duty.

References

1) University of Texas Medical Branch, Department of Pathology,

Pathology Clinical Services, Transfusion survival guide, Blood

Bank Division, August 26, 2004

2) Ritchard Cable, Brian Carlson, Linda Chambers, Jerry Kolins,

Scott Murphy et al. Practical Guide for Blood Transfusion – A

compilation from recent peer reviewed literature. Developed by

the American Red Cross Biomedical Headquarters. May 2002.

3) Blood Transfusion Committee, Queen Elizabeth Hospital,

Barbados. Guidelines for Transfusion of Blood and Blood

Components. January 2002

The Menopause – A DiscussionDr Carlos Chase, MBBS, DGO, CLM, DM

The Menopause is the cessation of menstruation for a minimum

period of six months.

The climacteric is that peri-menopausal period where symptoms

are experienced by the patient. The average age of menopause in

the USA is 51 years, ranging from 47 – 55 years. This range is not

affected by race, socioeconomic status, number of pregnancies,

OCP, education, alcohol, age of menarche, or date of last pregnancy.

Cigarettes have only been conclusively shown to hasten follicular

exhaustion.

Menopause is due to ovarian failure, leading to reduced

oestrogen output and increased FSH and LH production, which

occurs within one year of the cessation of menses. The organ

systems affected are wide and varied. The combination of

senescence and hormone lack may manifest with symptoms and

signs so varied that some physicians incorrectly attribute all

symptoms in this period to gonadal failure.

Ageing:

Let’s look at some effects on the organ systems.

The Nervous System: Normal ageing leads to a brain loss of 5 to

10% of brain weight and a reduction of 20 to 50% of brain cells.

Cerebral blood flow is reduced and does not correlate with cognitive

18

C I T A T I O N

BAMP Banquet, 2009, Accra Beach Hotel

Through some strange quirks of fate, none of the three BAMP

members who were asked to do Ermine’s citation – namely

Dr Abdon DaSilva, Dr Opal Gibson or myself are able to be here

this evening to pay tribute in person to this years recipient of BAMP’s

Award of Excellence.

All three of us, colleagues and friends of Dr Belle’s, are

disappointed not to be present We are grateful to our esteemed

President Dr Chase who has graciously agreed to read Ermine’s

citation. It is probably serendipity and most fitting Dr Belle that your

citation should in fact be read by the most prestigious officer in the

organization, our President, Dr Chase.

Dr DaSilva put some initial thoughts on paper before he realized

that he could not be present due to his son’s graduation in Canada.

He wrote”during a time of increasing public cynicism, recognizing

and honouring our leaders has never been more important. Despite

its young age, the BAMP Annual Award has become the profession’s

pre-eminent award for individuals who make an extraordinary

difference to our profession, our communities and our country.

This years awardee continues to remind us that individuals acting on

principle, and who choose first and foremost to act for the good of

their community and country, can make an extraordinary difference.”

He further describes Ermine as “a moving force and guiding spirit

for all of us”.

I concur with everything Dr DaSilva has written. In accepting the

honour of having been asked to complete this citation, I am delighted

to have the opportunity to share some of what I know about Ermine

and her career and to share with you some of the humanity of this

lady whom we honour tonight. I could not do otherwise as I attribute

much of my own early development working in the field of HIV, to

Ermine’s mentoring.

A Barbadian, the daughter of two educators, both of whom were

Head Teachers, Ermine, was the product of St Stephen’s Primary

School and Queen’s College.

Interestingly she describes herself as a ‘paediatrician since the age

Citation to Dr. Ermine Belle

of five’. However, as will so often happen, fates intervened and her

career path veered when she did not get a job in Paediatrics. Instead

she stayed on in Jamaica after her graduation in 1976 to pursue a

career in Psychiatry. Both her under-graduate and post-graduate

training were done at Mona where she gained her D.M in Psychiatry

in 1984.

I gather from Ermine that she may well have stayed in Jamaica if

had it not been for a patient who, as I understand it, wove her future

in to his reality and Ermine somewhat reluctantly returned home to

Barbados as she describes it “under siege”, in 1983.

At face value, Ermine’s professional life has been spent in

psychiatry but even minimal reflection makes you realize that her

contributions to our professional organization, to the AIDS program

particularly in the early days, to the community and as a surrogate

mother in her later years, make it virtually impossible to determine

where her greatest contribution lies.

Let me say to Ermine’s family who are here tonight that many of

us consider Ermine’s finest moments were in 1994, when while still

coping with the grief of the loss of her sister Mary who had lived much

of her adult life in Africa, Ermine seemingly without missing a beat

accepted the responsibility of transitioning from a visiting aunt in

Nigeria to being surrogate mother to five of Mary’s children,

right here in Barbados.

Fifteen years later, these five children are a testimony to Ermine’s

unselfish commitment to duty but also to her ability at that stage in

her life to fully embrace motherhood and the total lifestyle change

equired in order to organize a household of six, various school pick-

ups, extracurricular activities and all. Her change in vehicle to a larger

and more robust form of transportation signaled to us that she had

fully accepted her role and made the transition. Enter for the next ten

years Ermine the paediatrician and the mother.

Today these children in their different stages of life, the youngest of

whom is now twenty two years old, are living testimony to the quality

and character of this astounding lady.

C M E   / C L I N I C A L   G U I D E L I N E S . . . cont’d

B A M P 2 0 1 1

functions. All persons show deterioration in short term memory. Thermoregulation is problematic and the senses are less acute.Postural hypotension, slowness of movement and reduced rate oflearning may occur.

CvS: Reduced cardiac reserve with hypertrophy of themyometrium and calcification of the heart valves.

RS: Reduced lung compliance and some emphysematous changesoccur.

CU: Reduced ability to clear drugs due to decreased plasma flowand cardiac output with lack of concentrating ability of the kidney.

GI: Dysphagia, constipation and increased incidence of gall stones,

carcinoma and diverticulosis.

Immune System: There is a reduced antibody response of

B-cells and an increase in auto antibodies.

Skin and musculo-skeletal systems: There is a loss ofsubcutaneous fat and elasticity with age, with reduced healing andincreased susceptibility to trauma, and reduction in the articularcartilage in the joints.

In the climacteric woman, changes peculiar to these organ systemsoccur. (part 2 of this article will be continued in the next issue.)

B A M P 2 0 1 1

... continued on page 28

written by Dr Carol Jacobs and delivered by BAMP President, Dr. Carlos Chase

19

Sabga Awards for 2011BAMP is pleased to hear of the recent announcement that our

col league Professor Surajpaul Teelucksingh, Professor of Medicine

at the St. Augustine Campus, UWI, Trinidad and Tobago is one of

this year’s recipients of the Dr Anthony N Sabga Caribbean Award

for Excellence. The award is an initiative of the ANSA McAL

Foundation, and is fully funded by them. The announcement

declared: “Professor Teelucksingh is a highly-respected clinician

and teacher at the University of West Indies, St Augustine. He has

done ground-breaking work on the management of Chronic Non

Communicable Diseases, and his work on dengue haemorrhagic

fever and dengue shock syndrome is used as a guide to the treatment

of the diseases in the region. He has helped the Faculty of Medical

Sciences to redesign its assessment procedures to ensure better

trained doctors.

The two other awardees for 2011 are Dr. Lennox Honeychurch,

eminent historian, archaeologist and conservationist of Dominica,

and Kim Johnson, Trinidadian film maker.

N E w S   I T E M S   A N D   N O T I C E S

B A M P 2 0 1 1

News from the National Commissionfor Chronic Non- Communicable Diseases (NCCNCD)

Over the last several years one of the new, and long advocated,

developments on the local medical scene has been the establishment

of the National Commission for Chronic Non Communicable

Diseases (NCCNCD). The Commission was established in 2007 to

advise the Minister of Health on all matters related to chronic

diseases at the national level and to serve as an umbrella body,

catalyst, and a central point for mounting effective responses to the

chronic diseases. Since its formation the Commission has responded

in several ways to the challenges presented by exposure to cigarette

smoke and by the 54, 000 hypertensive, 16,000 diabetic and

two thirds of females and one third of males who are obese or

significantly overweight.

The Commission was one of the major contributors to preparation

and passage of No Smoking legislation in public places, the banning

of sale of tobacco products to minors and the increased taxes on

cigarette products, and it has launched a “National Nutrition

Improvement and Population Salt Reduction Campaign”.

Many initiatives in regard to the latter including low salt

advertisements on television, articles in the BARP Bulletin, Better

Health Magazine and local newspapers, support for a locally

produced nutrition and recipe book ”Lower your blood pressure in

14 days”, sponsorship of Agrofest 2011 with the theme "achieving

healthy lifestyles through agriculture", and workshops for food

vendors, food producers and manufacturers.

Finally, the Commission will be supporting a Caribbean–wide

social and traditional media Risk Factor and Chronic Disease public

education campaign that will soon be launched. This will seek to

obtain one million text messages of support from Caribbean people

for a United Nations meeting of World Leaders to be held in

September.

For further information on chronic disease in the Caribbean visit

www.healthycaribbean.org or contact Ms. Sheena Warner at

warnersheena@gmail.com.

The new Medical Registration Act has been in gestation for

many years …. Far longer than that of the elephant (23 months).

It was debated in Parliament in January and BAMP looks

forward to the introduction of the several recommendations it has

made over the years, but with perhaps some concern about the

adequacy of the preparations needed for managing some of the new

proposals. Both specialist registration and mandatory continuing

medical education (CME) have been talked about for years, and

both need marked upgrading of the management systems and

resources. The BAMP / UWI partnership in CME has been an

outstanding success in terms of regular, high quality conferences,

but with mandatory CME for all doctors, they have been of benefit

only to the 10 – 20 % of the converted. And the totally inadequate

support system of the Medical Council needs to be urgently brought

into the 21st century to achieve the intended goals. Discussion of

these issues will feature in the next issue of the Bulletin.

The New Medical Registration Act

News has been received of the sudden death on February 12th of

Jamaican plastic surgeon Dr. Tony Jackson, of a massive my

ocardial infarction, on his 69th birthday. Dr. Jackson was a graduate

of the Class of ’69, UWI, and a classmate of Drs. John McConney,

Henry Fraser, Carol Jacobs et al. Following internship at QEH,

he worked there as a resident from 1970 to 1972 with Sir Jack

Leacock, before undertaking his further postgraduate training

in plastic surgery.

Tony will always be remembered for his energy and wit, his love

of life and love of music, and his sartorial elegance. Even in the

nature and date of his departure, on his 69th birthday, there was a

certain matching precision and flare.

The members of BAMP extend our deepest sympathy to his wife,

family and friends in Barbados, Jamaica and around the world.

NEwS - Dr. Tony Jackson

New girl friend: " But you told me your father

was a doctor. Now I discover he's a

mortuary attendant."

Young man, trying to impress: "I told you the

truth, but you got it wrong.

I said: "He follows the medical profession."

20

F M S R E P O R T

B A M P 2 0 1 1

Faculty of Medical Sciences, Cave Hill:Report September – December Academic year 2011-12

After 33 years of service, Professor Henry Fraser retired from the

University in September 2010. His post of Dean was filled by

Professor Joseph (‘Mike”) Branday, previous Deputy Dean for Med-

ical Education and Curricular Affairs at the Mona Campus.

Also in September, Professor Nigel Unwin was appointed to the

Chair in Public Health, vacated by Professor Jose Ortega. Under his

guidance, it is planned to add to our Masters in Public Health with

the introduction of the Doctorate in Public Health at Cave Hill in the

coming academic year.

In September, the Faculty accepted its third contingent of almost

70 undergraduates into the new full five-year programme. The

majority of these students are from Barbados or Trinidad & Tobago

CERTIFyING THE ELDERLyTO DRIvEBy Dr. Michael Hoyos, General Practitioner and Senior

Lecturer in Community Medicine UwI, (ret.)

Certifying the elderly to drive must begin with a thorough history.

As is common the social history is of paramount importance.

Does the patient smoke? Or use alcohol? And if so, how much and

how often? Is illegal substance use an issue? Is he / she still

employed or self-employed? What family and other support

systems are in effect? Other aspects of the history include:

Past Medical History – previous depression, psychosis, chronic

disease with particular reference to those involving cerebral and

cardiac function such as epilepsy, arrhythmias, and longstanding,

poorly controlled diabetes mellitus and hypertension. Have there

been previous eye diseases such as glaucoma, which is very

common in our society, or cataracts.

Drug History – What medication are they taking, for how long and

with what adverse effects?

There are many who will advocate that a complete and

comprehensive medical examination is the best course. The

problem with this, if there is in fact a complete examination, is that

it is time consuming, may not all be possible at the same sitting

and is quite an ordeal for the patient. The physical examination

should be targeted to discover the common problems that affect

the elderly and those that may make driving dangerous.

Eye Examination: This must include visual acuity with and without

corrective lenses that are used for driving, peripheral visual fields,

eye movements (cranial nerves 3, 4, and 6) and opthalmoscopy to

determine early lens opacities.

General Examination: The overall appearance of the patient.

Their gait, affect, emotional state etc. should be noted, including

any deformities, tremors orany deformities, tremors or instability.

Urinalysis, blood pressure, peripheral pulses, pallor, jaundice,

may

The first cohort of first year students (Class of 2013) is now in the

third year of the full programme. They commence their first rotating

clerkships in Child Health, Medicine and Surgery in January 2011 in

preparation for their transition to Phase 2 and graduation in 2013.

During the summer semester this group participated in an

introductory research course that enabled nine students to undertake

externships in Canada (MNI), the UK (King’s College, London) and

St. Lucia. Two of the research papers that arose out of the course have

been accepted for presentation at the 2011 scientific meeting of the

Caribbean Health Research Council in Guyana.

The major challenge facing the Faculty at this time is the delay in

the start of construction of the proposed clinical teaching complex

adjacent to the Queen Elizabeth Hospital. The expanded facilities and

the provision of new clinical posts are critical to the sustainability and

expansion of the Faculty in Barbados. These, along with the signing

of an MOU with the Hospital, will be important steps in achieving

continued accreditation by the Caribbean Accreditation Authority

when they revisit the University in 2012.

dehydration, tremor, are all part of the general observations that

may provide a red flag to hidden disease that should be treated prior

to being certified to drive in the over 70 year old.

Central Nervous System: This is important to detect deterioration

of the nervous system due to age and the presence of early changes

due to disease such as small strokes, Parkinson’s etc. Examination

of the cranial nerves other than those concerned with vision is

appropriate particularly the 7th nerve (facial), 8th (hearing) and 9th

(palate) and the motor and sensory aspects of the peripheral nervous

system including coordination. Tests for slowing of reflex which

correct balance have long been used by police in regard to the

influence of alcohol (walking a straight line etc.), and these reflexes

slow significantly with aging. In this regard a useful test is the “one

leg test”. The patient must be able to stand on one leg for 5 seconds

without losing balance.

Cerebral Function: Examination of cognitive function is

important to uncover Alzheimer’s disease and multi-infarct

dementia. These conditions are common in the elderly and more

importantly these are of insidious onset and may not be obvious

for some time. To examine for this the mini-mental state

examination or other tests of cerebral function are recommended.

CONCLUSIONS

Examination of the elderly for the certification to drive a motor

vehicle must entail a relevant history which includes a social and

family history, and information on past diseases and drug use.

Physical examination should be specifically targeted to ensure

adequate function of the eyes, central nervous system, cardiac and

cerebral function (cognition). There is a need for a standardized

form to ... continued on page 28

By Professor Joseph “Mike” Branday

21

N E w S   I T E M S   A N D   N O T I C E S . . . cont’d

B A M P 2 0 1 1

69TH BAMP/UwI CME CONFERENCE

Agenda:

1) Dates & venue

2) AGM

a) Notice: 21 days before 14th May

b) Elections for:

i) 1st Vice President

ii) Secretary

iii) Asst Treasurer

iv) PRO

v) 2nd Floor Member

vi) 4th Floor member

vii) Vacated Posts

c) Notice: 6 weeks before AGM

d) Nominations: 2 weeks before AGM

e) Presiding Officer

3) Scientific Programme

a) Session I

b) Session II

c) Session III

d) Session IV

e) Session V

4) Banquet

5) Registration

6) Sponsorship

7) AOB

69th BAMP/UwI CME and Annual Banquet

Registration for CME Conference,“Medley of Medical Updates”venue: Lloyd Erskine Sandiford Conference Center, Barbados.

REGISTRATION: (Pre-registration ends May 6, 2011)

By telephone at +246 429 7569 Ms. Angela Phillips

By mail: fill in and send the registration form with a bank draft,

money order or credit card information to:

Barbados Association of Medical Practitioners,

BAMP Complex, Spring Garden, Barbados.

Please make bank drafts or money orders payable to:

Barbados Association of Medical Practitioners

By fax: fill in and fax the registration form with credit card

information to (246) 435-2328

Attention: Ms. Angela Phillips

By email: fill in the registration form with credit card information,

scan the registration form and email to info@bamp.org.bb

Attention: Ms. Angela Phillips.

Online: Please check online at www.bamp.org.bb for Registration

on a secure server

22

Venue: Lloyd Erskine Sandiford Conference Center, Barbados. (Pre-registration ends May 6, 2011) O Mr. O Mrs. O Ms. O Miss O Dr. ____________________________________________________________________________ (Please print name in the form you wish it to appear on your Certificate) Organization:___________________________ Position/Occupation:_________________ Address:____________________________________________________________________ Phone # (____)_______________________Fax # (_____)_____________________________ E-Mail Address:______________________________________________________________ Name to appear on your name tag: _______________________________________________ YES NO FEES I am a BAMP member [ ] [ ] I will attend BAMP Annual General Meeting [ ] [ ] Nil I will attend 1st day of CME (14th May) only [ ] [ ] _____ I will attend 2nd day of CME (15th May) only [ ] [ ] _____ I will attend both days of CME (14th & 15th May) [ ] [ ] _____ I will attend the Annual Banquet (21st May) [ ] [ ] _____ I will be accompanied by ___ guests to the Banquet [ ] [ ] _____ I prefer Vegetarian Meals (Pre-Registration ONLY): [ ] [ ] Total Fees _____ This information is being obtained through a Secure Server Credit Card Option O VISA O MASTERCARD Card #_____________________________________ Card Holder Name:__________________________________________________________ Expiry____________________________ Payment amount: $________________________ Today’sDate_____________________Signature_________________________________

Venue: Lloyd Erskine Sandiford Conference Center, Barbados. (Pre-registration ends May 6, 2011) O Mr. O Mrs. O Ms. O Miss O Dr. ____________________________________________________________________________

(Please print name in the form you wish it to appear on your Certificate) Organization:___________________________ Position/Occupation:_________________ Address:____________________________________________________________________ Phone # (____)_______________________Fax # (_____)_____________________________ E-Mail Address:______________________________________________________________ Name to appear on your name tag: _______________________________________________ YES NO FEES I am a BAMP member [ ] [ ] I will attend BAMP Annual General Meeting [ ] [ ] Nil I will attend 1st day of CME (14th May) only [ ] [ ] _____ I will attend 2nd day of CME (15th May) only [ ] [ ] _____ I will attend both days of CME (14th & 15th May) [ ] [ ] _____ I will attend the Annual Banquet (21st May) [ ] [ ] _____ I will be accompanied by ___ guests to the Banquet [ ] [ ] _____ I prefer Vegetarian Meals (Pre-Registration ONLY): [ ] [ ] Total Fees _____ This information is being obtained through a Secure Server Credit Card Option O VISA O MASTERCARD Card #_____________________________________ Card Holder Name:__________________________________________________________ Expiry____________________________ Payment amount: $________________________ Today’sDate_____________________Signature_________________________________

Registration for CME Conference, “Medley of Medical Updates”venue: Lloyd Erskine Sandiford Conference Center, Barbados.

23

M E D I C A L   S T U D E N T   v I E w S

B A M P 2 0 1 1

Our Experience at the Montreal Neurological Institute - July - August 2010

The Faculty of Medical Sciences (FMS), University of the West

Indies (UWI), Cave Hill awarded nine (9) third year student

applicants externship experiences at three international institutions,

Montreal Neurological Institute (MNI),McGill University, Canada,

Kings College London, United Kingdom and Victoria Hospital,

St. Lucia. These experiences were presented to successful applicants

who were undertaking their Understanding Research Course

(MDSC3200) during the summer semester, and were awarded on a

competitive basis. We, Brittany Carter, Isha Emmanuel, Nicole

Simpson, went to the Montreal Neurological Institute (MNI) and

would like to share our experience with other colleagues and the

wider campus community.

Never at this stage in our medical career did we ever think that an

opportunity such as this would have been presented to us. The MNI

is a unique centre dedicated to neuroscience, neurology and

neurosurgery. Generally in the past there has been a great divide

between basic scientist and clinicians to incorporate findings of basic

science into patient care. However, during our visit we found that

the MNI truly exemplified the meaning of teamwork, as basic

scientists and clinical scientists work together harmoniously under

one roof to provide fundamental information about neuroscience and

apply that knowledge to understanding and treating neurological

diseases. This clearly shows that it is neither impossible to translate

basic science into clinical practice nor for clinicians to be scientists.

If there is one thing that we all take away from this experience is that

there is no greater gratification in patient care than when you, as a

clinician, are part of a team that finds a medical breakthrough, and

that is exactly what each of us plan to strive for in our medical career.

The externship presented an opportunity to apply the knowledge we

have acquired thus far, improve our research and presentation skills,

and learn how to develop project ideas as well as provide insight into

a neurological career. The rotations through the clinics provided

a platform for an even stronger resolve in our pursuit to become

physician –scientists.

During our three week stay in Montreal we were provided with a

very well detail-oriented schedule in order to gain an understanding

of the holistic functioning of the Montreal Neurological Institute.

The rotations ranged from visits to research units in Epilepsy and

Treatment, Multiple Sclerosis and Treatment, Neuroimmunology,

Neuromuscular Disease, Cognitive Neuroscience and Brain Imaging,

to the viewing of a tumour removal and how neurological exams

are conducted. Through these rotations, we saw firsthand how the

institute provides an ideal environment for basic science research to

translate into clinical practice as the experts are readily available to

apply their findings to improve the patient care of those suffering

from neurological diseases. In this way, patients are able to benefit

greatly from the intimate association between basic and clinical

scientists, receiving treatment for a wide range of neurological

disorders such as brain tumours, multiple sclerosis, Parkinson’s

disease, migraines and epilepsy. What we found most exciting

however, were the amazing technological advances in which patients

Brittany Carter, Isha Emmanuel, Nicole Simpson

(Medical Student Report)

benefit from such as neuro-radiology, neuro-engineering,

neurostimulation, neuro-navigation and brain imaging. The passion

and dedication demonstrated by many of the scientists are important

for working in the field of research. On reflecting on our own research

experience, it could be surmised that research may be difficult,

time consuming and many hurdles tend to appear during the course

of a project.

As a result, we all now firmly believe that it is pertinent that all

medical institutions aim to provide an environment where basic

scientists and clinical scientists can work successfully together to

improve patient care.

It is our hope that programs can be implemented where medical

students and young doctors from the Caribbean are able to receive

training from institutions like the Montreal Neurological Institute to

learn from the best, return home and impart the acquired knowledge

and skills to the region. It is imperative that in these times we heighten

the awareness of basic science research and its impact on clinical

practice. This aspect should be emphasized in the curriculum to

produce physicians who not only treat but find answers.

We greatly appreciate the effort of the Faculty of Medical Sciences

for affording us this opportunity, as this experience continues to linger

in our minds, shaping our thoughts, taking over our perspectives,

showing us the way forward. With the increase in chronic diseases,

infectious diseases, neurological diseases, the Caribbean has to find

ways to develop its research field and become self sufficient to an

extent while collaborating with already established world renowned

hospitals and institutions like the Montreal Neurological Institute.

In our estimation, we believe that the answer lies in this budding

relationship with the MNI.

Plea to the DoctorThe doctor is a worthy one;

His patients claim he's heaven sent (or she)

The man is knowing, erudite;

But holy cats! He just can't write!

The surgeon's hands are deft and skilled;

The surgeon's head is know-how filled.

Yet why - since he's so doggone bright -

Cannot the surgeon learn to write?

Dear sons of old Hippocrates

Pray hear a troubled nurse's pleas:

Remember that the gals in white

Have got to READ the stuff you write!

Your physicals and huistories,

Like Dead Sea Scrolls, are mysteries;

Your order sheets make nurses squint;

So please, dear docs, write RIGHT - or print!

Cecilia Hargrove, R.N.

Adapted from RN © 1960; 23 (March): 62.

24

H I S T O R y   O F     M E D I C I N E

B A M P 2 0 1 1

The 1854 Cholera Epidemic in Barbados

Dr Cheriann Catwell, MBBS

Karl Watson, in his book ‘Barbados First,’ alluded to the fact that

the washerwomen, who mainly worked in Bridgetown, washed the

infected clothes of visiting sailors (Figure 1.)

Interestingly, it was thought that the cholera epidemic of 1854,

which resulted in the deaths of over 20,000 Barbadians in

approximately three months, was brought to the island by the

steamship H.M.S. Dauntless or the Dervant - which transported

seamen who died of cholera on its passage here; among the dead

were two Barbadians. The clothes of the two soldiers were reportedly

given to a washerwomen in Jemmonts Lane to wash. It was at her

house that cholera was said to have its genesis in Barbados.

Another theory postulated that the epidemic started as a result of

some poor people consuming infected flying-fish (two days old)

which were sold in a semi-rotten state.

Tony Vanterpool in The Scrapbook at the Archives stated in his

Weekend Nation newspaper article of

14 February 1992 that The Barbadian

(a local newspaper) recorded statistics

on the mortality rate of cholera in 1854.

For example, it noted that 490 persons

from St. Philip died—38 were white

and 452 Colored and Black-on 10 July

1854.

Also, by 17 July 1854, 655 died - 45

White and 610 Colored and Black.

Also, by July 1854, the Barbadian

newspaper recorded some 20,000

persons buried from cholera.

Statistics from ‘The Report upon

Population in Barbados 1851-1871’

made reference to the deaths of Cholera

by parish during the periods 1853 – 55

(Tables 1 & 2.) 0000000Fig 1. Picture of Washerwomen at Indian River, St Michael

Cholera, also called Asiatic cholera, is an infectious disease of

the gastrointestinal tract caused by the Vibrio cholerae bacteria.

These bacteria are typically ingested through drinking water

contaminated by improper sanitation or by eating improperly cooked

fish, especially shellfish.

Cholera affects the intestines, causing diarrhea, severe fluid and

electrolyte loss, and, if untreated, death. The symptoms are severe

and range from vomiting, diarrhea, muscle cramps and dehydration.

This disease reportedly originated in Jessore, in the Ganges Delta

in India, causing an epidemic outbreak in 1780. However, mention

of this illness was found in data over 2000 years ago by Hippocrates.

Owing to improved methods of travel, the disease spread across

the Far East, Middle East and Europe. Thus, it was believed that

cholera was introduced into Barbados and the West Indies in the

1850s from the British colonies.

(This article was written as an assignment (topic of choice) for the Medical history essay in the Medical Humanities clerkship and was awarded joint first price).

H I S T O R y   O F     M E D I C I N E . . . cont’d

B A M P 2 0 1 1

Source: Governor Rawson C. B., Report Upon the Population of Barbados1852-71, 1872, page 7

Source: Governor Rawson C. B., Report Upon the Population of Barbados 1852-71, 1872, page 7

Fraser, Carrington, Forde and Gilmore in A-Z of Barbadian

Heritage recorded that many persons were buried alive. These

authors noted that many persons close to death were buried

prematurely in order to control the disease. My grandmother, in one

of her Barbadian stories, reported that she remembered her mother

talking about many people who were buried alive at Indian River

from a very bad illness (she didn’t know the name). She mentioned

that her great grandmother escaped this plaque.

Tony Vanderpool in his nation newspaper article 14 February

1992, ‘If yuh dead, yuh dun dead,’ noted one of the famous cholera

stories of that era. It referred to a man, who after being pronounced

dead by his doctor in the St. Michael area, was immediately placed

n a crate by an undertaker and transported to Indian River burial

00000

ground at Lands End. While on his journey, the reportedly dead

cholera victim knocked on the box and shouted “Gimme a break!

Ah living! Let me out!” The undertaker replied, “De Doctor say yuh

dead! Wuh yuh want me to say… Yuh living?” This response from

the undertaker was attributed to the fact that he was given handsome

fees for burying the ‘dead.’ Unfortunately those undertakers

died from this illness.

Reverend J. Y. Edghill in his book, Beyond Barbados, in 1890

described the phases of the disease. He made mention of events

such as: “pain was frightful and cramp would double up the body.”

“In another reference he noted there would be no pain only a collapse

of the whole system, with blue surface and awful coldness.” Edghill

also lauded the efforts of medical doctors including Doctors Francis

25

space and grossly inadequate sanitary conveniences Figure 2.

There were instances of more than thirty houses crowded together in

20,000 square feet of land. Dr Reeves reported seeing 11 children

and 6 adults occupying a dilapidated 18 feet by11 feet wooden house.

Moreover, there was no proper potable water or refuse disposal

system. Sewage and refuse were often left to accumulate around the

towns. Lewis Samuels, a civil engineer from Trinidad, in his report

on 14 November 1854, stated that the first thing Barbados needed

was pure water. During that time, water was obtained from wells and

springs and sold at 2 cents for four gallons with the result that only

the rich could afford it. Moreover, when water was available to the

less fortunate, their main priority was consumption with little left

for hygiene purposes–bathing, washing the yard, etc. These adverse

conditions exacerbated the spread of diseases especially among

the poorer classes.

Another factor which led to the rapid transmission of this disease

was the lack of accessibility and affordability of doctors by the public.

The majority of the population could not afford to pay doctors.

Furthermore, many persons were reluctant to go to doctors as they

had many myths and in some cases were ignorant of the help they

could have received from them.

According to The Barbadian, both the authorities and the

public were to blame for the poor health. The article suggested that

following Emancipation, most of the Barbadian population took

advantage of their freedom and became carefree. They defied public

opinion, and private admonition and many became complacent

and content with living in substandard conditions and eating

unwholesome food.

Alvin Carter reported Reverend Butcher as stating that when the

cholera epidemic occurred in Barbados, the country was unprepared.

He further noted that this should not have been the case since in

Barbados, authorities were informed, via the Barbados Globe

newspaper, of other cholera epidemics which

occurred in Jamaica and Britain. Furthermore, the

Barbados Authorities were fully aware that in a short

time over 500 persons died from cholera in Jamaica.

Unfortunately, Barbados did not take heed thereby

contributing to the outbreak.

As a result of the unfortunate saga of events, a

number of systems were put in place to prevent

another disaster as listed:

1. An act was passed to prevent the occupation of

abandoned wooden houses and hovels in

Bridgetown, and to provide for their removal;

and for the improvement of dwellings for the

poorer classes.

2. In 1856 the Board of Health was given the power

to make regulations for promoting the health of

the inhabitants and reme dying of conditions

likely to produce epidemics.

3. Piped water was introduced into the city by Civil Engineer Lewis

Samuels on 29 March 1861.

Even though Barbados has made novel progress in eradicating

cholera, the island has by no means arrived or can afford to relax its

environmental vigilance. We must ever be mindful that health for all

26

H I S T O R y   O F     M E D I C I N E . . . cont’d

B A M P 2 0 1 1

Gooding, Breton, Walton, Bradshaw and Walcott, whom he said

were very heroic in their efforts. He singled out Mr. M. Perkins, who

in Bridgetown, distributed medicines and food to the poor, lifted the

sick into the coffins when others refused, assisted the coffins to

the hearse, and going to the graveyard to ensure that they

were decently buried.

Owing to the high mortality rate of this dreaded disease, many

graves were dug in graveyards of The St. Leonard’s Church, Indian

Ground at Land’s End (between Fontabelle and Brandon), Dover,

St. Lawrence Gap, Cobbler’s Cave, and around St. George’s

Parish Church.

Following Governor Colebrooke’s orders that prisoners should

dig graves, many prisoners contracted cholera resulting in an

outbreak at Glendary. Sixty-seven of the 80 prisoners at Glendairy

contracted thisillness, with 23 of them being grave diggers.

Additionally, 20 patients at the Mental Hospital died, along with

all of the inmates and caretakers of the Home of the Destitute.

Despite the ignorance of both the Authorities and population in

Barbados about the pathogenesis of this disease, medical personnel

implemented some remedies in an effort to control the illness.

Alvin Carter in the The Journal of the Barbados Museum &

Historical Society, made reference to two types of treatments that

were implemented – allopathic and homeopathic – both of which

scored a 50% success rate, although homeopathy was the preferred

choice of treatment. The allopathic treatment which included

the use of Camphor (an aromatic compound obtained from the

cinnamonum camphora tree, used to treat serious gastrointestinal

disorders, spasmodic cholera and flatulent colic) dissolved in wine

or brandy and catechu–a preparation containing chalk, laudanum,

brandy and ammonia. Christmas bush and angostura bark were also

used. On the other hand, the homeopathic treatment included the use

of veratum, cuprum, turpentine and mustard.

During the early 1800s, the social conditions in Barbados were

described as deplorable. Apart from a general lack of education,

there was no formal public health system. The main priority of this

time was law, civil order and building roads while leaving health

neglected. There were poor housing conditions with little or no yard

Fig 2. Northeastern section of Bridgetown

27

is the journey we seek and never a destination we have reached.

In the regard, we need to plod on.

A word to the wise

In Barbados’s quest to control communicable disease and achieve

its Millennium goals, the following should be realised:

1. Although Barbados prizes itself for every household having

access to portable water, the Government must ensure that there

is 100% potable water connection to all householders rather than

the current 89%. This goal is not only ideal but achievable.

Government’s disconnections of water (usually among the poorer

class) for nonpayment or late payment should be discontinued.

Lack of adequate water availability and poor hygiene remain

potent catalysts of epidemic and ‘underdevelopment’.

2. Barbados should aim for having 100% waterborne systems to

replace the 13% existing pit latrines across the island.

3. There must be continued dissemination of public health

education and good hygiene practices in schools, to the public

and especially food vendors.

4. We still need to acquire a primary health care system that is

accessible and affordable and that is used by all citizens.

5. The Barbados Water Authority needs to address its 30% to 60%

leak in its water supply mains and the infiltration of stormwater

into its system following heavy rainfall. The prevailing scenario

constitutes a potential floodgate for infectious disease and

epidemic occurrence.

6. Modern Barbados must engage in holistic health and not merely

disease and ‘dis-ease’ arising from bacteria and viruses

associated with excreta. We must develop environmental

competency to save and promulgate total heath.

7. We must improve our wastewater treatment efficiency to reduce

impacts on the groundwater and marine environment from total

nitrogen, heavy metals, pharmaceuticals, hormones, fragrances

and other personal care activities.

8. The approach to wastewater management should be holistic

utilizing strategies for the sustainable management of domestic

wastewater, animal husbandry and crop production in the context

of the green economy while being cognisant of the

interconnectivity between groundwater and marine resources.

9. Indeed, Barbados needs a proactive environmental management

approach to reduce and maintain nutrient concentrations

(e.g. nitrates, etc.) in an acceptable level in its terrestrial and

marine environments and concomitant enforcement backbone to

assure such management.

10.Barbados needs to complement its Health Services Act, Cap 44

by the promulgation of environmental management laws. Indeed,

more than merely promulgating Sanitation and Health Service

Laws, Barbados needs to enforce them. We urgently need to

seriously develop an enforcement culture.

Conclusion

The cholera epidemic in 1854, which was reportedly brought

here by the British, caused severe morbidity and mortality to

approximately 1/7 of the inhabitants of Barbados in a period of three

months. The lack of education coupled with deplorable public health

H I S T O R y   O F     M E D I C I N E . . . cont’d

B A M P 2 0 1 1

conditions spawned rapid transmission of the disease.

The Government authorities and the population tried their best to

control this disease. Consequently, with development of Health

Regulations, expansion and improvement in the supply of potable

water, and improvement in general sanitation and primary health care,

Barbados could boast of being free from Cholera and other

communicable diseases. The country still needs to remain ever vigilant

in promulgating health education, improving its primary health care

and environmental sanitation concomitantly with enforcing relevant

Health Services and proactive environmental management laws.

References

Handa, S. Cholera’ Medicine. March 21, 2003.

http://www.emedicine.com/med/topic351.htm.

http://www.answers.com/topic/cholera

Howard-Jones, N. Cholera Nomenclature and Nosology: a historical

note in Bulletin of World Health Organization, 51:3. 1974.

Watson K. Barbados First the Years of Change. Barbados:

Cole’s Printery. 2003

Fraser H., Carrington S., Forde A. & J. Gilmore.

A-Z of Barbadian Heritage. Jamaica: Heinemann Publishers. 1990.

Butcher, T. ‘Mordichim’: Recollections of Cholera in Barbados.

London: Partridge, Oakley and Co., 1855.

Carter A. The Journal of the Barbados Museum and Historical

Society. Vol. XXXVII. No. 4.

Barbados: Barbados Museum and Historical Society. 1990.

The Barbadian, 26 July 1854.

Vanterpool, T. Scrapbook (Barbados Department of Archives)

pg. 11-12.

Rawson, R. C. B, Report Upon the Population of Barbados 1851-71

(Barbados: Barclay and Fraser, 1872) pg. 24-25

Fraser, H., Carrington S., Forde A. & J. Gilmore. loc. cit.

Vanterpool, T. loc. cit.

Edghill, J. About Barbados. London: C. Tallis & Co. Farrington.

1890.

Ibid

Edghill, J. loc. cit.

The Barbados Saturday Advocate, 22 February 1992.

Weekend Nation, 14 February 1992.

Ibid

Carter A. loc. cit.

Edghill, J. loc. cit.

Watson K. loc. cit.

Carter A. loc. cit.

Ibid

Ibid

The Barbadian, 5 July 1854.

Ibid

Carter, A. loc. cit.

If you enter a doctor's office and notice

that all of his pot plants are dead or

dying, get the heck out of there!

When I was asked to do this citation for Ermine my answer wasan unqualified yes even before I had decided whether I could trulydo Ermine’s contribution justice.

Way back in the late1980’s in the early days of the AIDS epidemic,in fact before we realized that this would be a pandemic, I joinedBAMP’s AIDS Taskforce. Ermine mentored me through my earliestcommunity presentations until the point at which I felt confidentenough to venture into rum shops and pastures to reach people wherethey were. I think at that point, Ermine’s acumen in the field ofpsychiatry came to the fore and she decided that was as far as hermentoring was required and she encouraged me to continue on myown. Let me use this opportunity to thank you publicly Ermine forthat mentorship and for always agreeing to assist whenever you havebeen asked to make presentations to any group on HIV/AIDS.

Let me now turn to Dr Belle the trade Unionist and committedBAMP member. I well remember BAMP Council meetings in the1990’s under successive Presidents when Ermine could always becounted on to support, organize, participate and when required leadthe organization. Between 1990 and 1999 she served BAMP as floormember, PRO, Vice President, Assistant General Secretary andGeneral Secretary. In fact Ermine’s tenure as General Secretary forfour years, speaks volumes to her ability to commit to a cause, as wellas her patience and her capacity for hard work.

Those were some of BAMP’s most testing days as a trade unionin the context of the then eight percent salary cut across the CivilService and the ensuing turmoil.

She ultimately served as President of BAMP through anothertempestuous season but those of us who had worked with her knewthat this too she would take in her stride.

I well remember BAMP Council meetings going on until almostmidnight on many occasions as we sought to grapple with the issuesof being a trade union while serving the needs of our professionalmembership and most important, serving our patients.

A previous BAMP President himself, Dr DaSilva, says of Erminethat” her actions were always grounded in firm principles and inthe belief that one always had to act first and foremost for the goodof the community and the country.”

Ermine’s ability earned her many appointments, among them tothe Child Care Board and the Drug Formulary Committee. She hastravelled to far-flung places to work, including a three month electivein Psychiatry in Benin City in Nigeria in 1981, a short termconsultancy with the Commonwealth Secretariat in Zimbabwein 1990 and a Training Forum on Policy-making and Servicedevelopment in Tunisia in 2002. She has made an extraordinarydifference wherever she has served, working with her trademark quietand selfless determination.

Ermine has other less well recognized talents, one of whichis her voice. Over the past fifteen years she has pursued thistalent, performing with both the Barclays Singers and the BarbadosFestival Choir.

On a personal note, I have to pay tribute to Ermine’s oratorical skillswhich influenced me many years ago. Possibly the mos remarkablevote of thanks I have ever heard was made by Ermine as she thankedthe usual list of participants without in any way listing them but ratherthreading them through her story in an effortless, gracious andhumourous way. I am still trying to perfect that art, Ermine.

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C I T A T I O N . . . cont’d

B A M P 2 0 1 1

form to record these clinical findings and this is a challenge for

insurance and medical professionals to take on.

PRACTICAL POINTS

Assessing Cognitive Function.

There are several tests that can be used to evaluate cognition.

Perhaps the most fully studied and easiest to use test is the

mini-mental state examination. This tests for:

Orientation in time

Orientation in space and place

Ability to recognize and name objects

Ability to read

Ability to think, tested by calculating the mathematical problem

of taking 7 away from 100 and continuing to take 7 away from

the numbers they get.

Evaluation is scored and for further information the reader is

referred to M.Folstein 1975, J Psychiatric Research 12, 189-198.

Stopping The Senior Citizen From Driving

This is not an easy task and usually cannot be done at one sitting.

An aggrieved patient merely has to seek a second opinion and

driving may well continue. Care and compassion is necessary

and the problem needs to be anticipated maybe 2 or 3 years

in advance, family members should be involved and their

assistance elicited.

continued from page 20...

CERTIFyING THE ELDERLy TO DRIvE

However, let us not forget the core of Ermine which is Ermine the

psychiatrist quietly but effectively performing her role as Senior

Consultant Psychiatrist at the Psychiatric Hospital, but also as a

community psychiatrist where she served from 1987 to 1995. She has

provided support for innumerable people who count her as doctor but

also as friend. Dr Opal Gibson, who is also unavoidably absent, could

think of no better person than her friend Ermine to receive this

recognition tonight. Opal said and I quote ” we have been friends

through the years, for more than thirty years…ssh don’t talk too loud”

- they knew each other from when they were freshettes at Mona.

She continues, “Ermine has been my mentor in the last few years.

I have always known that I have a built –in therapist whenever I

wanted and it has certainly come in handy with my journey through

life over the years. As a colleague she is always available on the other

end of the line whenever I have a problem with my psychiatric patients.

Ermine is not only my friend but my esteemed colleague. I know that

whenever she ponders on anything her eyes look up to the sky, she

folds her arms and then produces the exact answer required.

Ermine sorry I could not be there in person but I am with you in spirit”.

Ermine continues to serve her friends as well as the widest

community with assignments ranging from the Commission of

Ministries for Anglicans, to the Commission which she now chairs,

the National Mental Health Commission.

Dr Belle, BAMP is proud tonight to recognize your immense and

varied contributions not only to BAMP but to the wider community,

both in Barbados and regionally. We salute you as the 2009 recipient

of BAMP’s Award of Excellence.

... continued from page 18

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Lifestyle-related diseases such as heart disease, cancer, diabetes, hypertension, stroke and obesity are spreading through our region, and continue to create serious social and economic challenges. We must all seriously commit to doing our part in promoting increased physical activity and healthy eating to live longer, healthier lives.Sagicor also supports the regional goal that, by 2012, 80 percent of people with non-communicable chronic diseases will receive quality health care and have access to preventative education.LIFE INSURANCE | GENERAL INSURANCEASSET MANAGEMENT | MORTGAGES

SINCE 1840CARIBBEAN | LATIN AMERICAUNITED KINGDOM UNITED STATES OF AMERICARATED “A -” (EXCELLENT) BYRAA ) BY

HEALTH IS A STATE OF COMPLETE HARMONY OF THE BODY, MIND AND SPIRIT.

Lifestyle-related diseases such as heart

disease, cancer, diabetes, hypertension,

stroke and obesity are spreading through

our region, and continue to create serious

social and economic challenges. We must

all seriously commit to doing our part in

promoting increased physical activity and

healthy eating to live longer, healthier lives.

Sagicor also supports the regional goal

that, by 2012, 80 percent of people with

non-communicable chronic diseases will

receive quality health care and have access

to preventative education.

LIFE INSURANCE | GENERAL INSURANCEASSET MANAGEMENT | MORTGAGES

SINCE 1840

CARIBBEAN | LATIN AMERICA

UNITED KINGDOM

UNITED STATES OF AMERICA

RATED “A -” (EXCELLENT) BYRAA ) BY

HEALTH IS A STATE OF COMPLETE HARMONY OF THE BODY, MIND AND SPIRIT.

00