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Bahamas Medical Journal


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Bahamas Medical Journal
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Medical Association of the Bahamas
Medical Association of the Bahamas
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Nassau, Bahamas
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completely irregular


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Medicine -- Bahamas   ( lcsh )
serial   ( sobekcm )
periodical   ( marcgt )
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College of the Bahamas, Nassau
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College of the Bahamas, Nassau
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BabamtUMedicalJournal(IncorporatingBahama-Med1984-1988)AJournalforallMedicalPractitionersPublishedByTheMedicalAssociationofThe Bahamas,EDITORIALBOARDEditor'andTechnicalProducerExecutiveProducerandPrincipalEditorialConsultantFinanciallContmllerDirectorofAdvertisingEditorialConsultantsInternationalAdvisorsDr.JoseColacoDr.EugeneNewryDr.WilliamsonCheaDr'.ElizabethDarvilleDr.GlenBeneby,Dr.KirtlandCulmer,Dr.GwenlVlcDeigan,Dr.HubertMinnis,Dr.RobinRoberts,Dr.MatthewRose,Dr.AdrianSav.yer,Dr.PhillipThompson,Dr.RichardVantoorenandDr.JulieWershing.Dr.AlipioBarros-Mascarenhas(Dallas),Dr.OrrinBarrow(Kingston),Dr.DavidBratt(PortorSpain),Dr.VinodDiwan(Stockholm),Dr'.AnthonyD'Souza(London),Dr.CharlesEdwar'ds(Bridgetown),Dr.BridieEgan-Mitchell(Galway),Dr.RenHolness(HaliFax),Dr.Michael Lee(Kingston),Dr.MichaelParker(London),Dr.ErnestPate(Kingston),Dr.JamesRust(\Vashington),Dr.AshokSamantha(Leicester)andDr.DincshSinha(Kingston).BAH.MED.J.welcomesthereproduction0/materialprintedhereinwiththeprovisothatadequaterecognhionisgiventothesourceandauthor0/theoriginalmaterial.Articles represent the viewsofthe authors andnotnecessarily thoseofthe journal.REFERENCESARENOTPRINTEDFORTECHNIC:\LREASONSBUTAREAVAILABLEWITHTHE./OURI'TALAllCORRESPONDENCETOTHEEDiTOR,BAH.MED.J.,BOX N 10 145 NASSAU, BAHAMAS


EDITORIALCOMMENTSInMarch of 1985 this column sent out an alert signal on AIDS. It was one of the first statements on the killer disease in the world and perhaps the earliest publicationonthe subjectinthe entire Caribbean. A special word of praise is duetothe Ministry of Health's AIDS team for the aggressive and comprehensive attack it has mountedinan effort to combat the different problems encountered. The AIDS team needs the continued support of every health care professional. Every attempt must be utilised to reinforce the message of prevention. A lullinour combined efforts will lead to complacencyonthe part of those at risk. Theresults of this can onlybedisastrous. This time we are sending out another alert signal. This one is on TRAUMA. Thereisanunbelievable number of peopleinthis world who are being traumatised physically, sexually and emotionally.Itis time now to take stock and for preventive interventions to be set in place. Physicians all over the world are seriously concerned at the escalation of violence which has taken place over the past few years. The emergency rooms are stretched to the limit, while dealing mainly with trauma related problems, most of which are avoidable. Thisisit we just cannot affordtotake any more of this, without diverting health care commitments from other areas.InThe Bahamas already for this year a score and more persons have diedinroad traffic accidents. Tragically too, a much greater number of persons are paralysed or otherwise maimedbythese incidents many of which could easily have been avoided. The gravity of the problem extends beyond the actual physical disability of the individuals concerned.Itinvolves relatives, the workforce, astronomical amounts of private and public expenditure and causes a strain on the health professionals and theheal1thsystem. While one is encouraged by the recent effort by the police and traffic departments to tightenupon the traffic violations there are several problems which merit special attention. Among them are non-functional street and traffic tights, 'traffic light runners' and 'zoomers', atrocious wrecks with recent inspection stickers, delivery trucks without appro priate safety railings, vehicles parkedinblind zones, young helmetless rent-a-bike riders who can barely manage their vehicles and a fewpublic transport buses driven with appalling road sense. We strongly recommend the installation of permanent radar surveillance, the regular policing of heavy traffic junctions, the mandatory use of seatbelts, spot testing for alcohol and other drugs and the hiring of traffic wardens empowered to impose fines for traffic violations, on site. There is widespread concern about the carnage on the roads and violenceingeneral. Violence at home, at school andinthe movies plays a significant roleinthe genesis of further violence. Thisisas good a time as any to commence a program of public education and perhaps for the revival of road blocks. The Medical Association of The Bahamas is willing to provide all the necessary assistanceinsuch a public education program. Preventive steps will eventually be more cost effective than crisis management. The Medical Association's recently held Annual Scientific Conference focused on the various aspects of trauma. The views expressed at the sessions are shared by almostalII,if not all physicians. There is just too much trauma around and most ofitispreventable. Nowitistime for the physician community to follow words with appropriate action. We all agree that preventionisthe best and the least expensive method to curb this disease. We have to instrument our own public education measures so that the public willbeable to fully understand the devastating impact of trauma on the physical, social and economic life of this country.Itis especially true for the Caribbean thatnocountry can thrive if it's residents and visitors feel unsafe on the roads or in their homes. The MAB will continue to press for the enforcement of existing laws and where necessary, for new legislation to make our roads, our homes and the environment safer. All this of course will have tobedone within the framework of human rights. Nobody is suggesting a panic approach, but there must be enforcement surely fair, humane and uniform enforcement of laws.Itisonly with this combined approach of legislation and education that we willbeable to change attitudes enough to ensure that we all will finally learn to buckle-up (children included), not drive under the influence and slowdown and live.'nr,'R.obill'R.obcrl.'i


Australia and Canada have documented decreased motor vehicle accident mortalitiesbyfigures of 25-30 percent with the introduction of seat belt legislation.InNova Scotia, the head injury statistics have fallen to 75/100,000 per year from previous figures of 150-200 which are still prevelantinthe United States.Inthe United States, where only 34 States have seat belt legislation and only 8 of those have primary enforcement laws.Asa result there has been very little dentonthe mortality rateinthe United States. Other measures that canbethought of are, strict enforcement of speed limit and redesign of roadways, etc.,allof which can onlybedone by a closestudy of the local situation. With regardtomotorcycle and bicycle accidents,itisclear that mandatory use of helmets has made a big differ enceincountriesinwhich these laws have been enforced. Unfortunately,inthe United States the helmet laws wererepealedinmany Statesin1976. Since then the head injury mortality for motorcycles has risenby40percent. Thisisa good example of freedom of choice gone amuck.Asfarashomicides are concerned, thisisa much more difficult and complicated problem. It is my view that handgun legislation and stricter control of private ownership of gunsingeneral make a big difference.InNova Scotia, we get more hunters damagedbyfirearms than people who are murdered, which amounttoa total of less than 5-6 peopleina population of 900,000/annum.Ithas been well showninthe United States that one out of six attempts of homicide with a gunissuccessful, versus one out of sixteen attempts with a knife.In1982 almost 50% of the 26,000 murders,inthe United States, were committed with hand guns. We could goonand on, but the fact that for each death duetoa particular cause of trauma, there are many injured and maimed and only by careful study of each causative factorcanappropriate preventative measuresbedesigned that would be indigenous to the particular population. Evenifone weretoestablish a more efficient epidemiologic surveillance system for trauma, and institute preven tive measures, as well as education, there still will exist the necessity for treatment of acute injuries. This will, of course, involve the improvement of pre-hospital treatment and transportaswellassystems of treating these patientsinthe local and referral centers.Ithas been repeatedly shown that with traumaingeneral, 85% of the patients canbetreated locally,10% require referral to a more sophisticated center and only 5%ofpatients really need the facilities and expertise of ahighly equipped trauma unit. The EMSandtrauma systems establishedinthe United States have much to commend them, and utilizing the principles gleaned from the development of such systemsitseemsasifa system designed for the Bahamas canbea realityinthe very near future. New Providence already has all the basic ingredients,Le.a rela tively well equipped hospital withanintensive careandoperative set-up well supplied with anesthesia and surgical ex pertise,aswellasadequate radiologic facilities, inclUding a CT scan, dedicated primary care physiciansandemergency physicians who are the initial linksinthe development of such a system.Inmy view, other personnel such as paramed ics, ambulance attendants and nursing staff shouldbetrainedandcertifiedinacute trauma careaswell. The best of systems are uselessifthe products,Le.the patients saved, do not have facilities for rehabilitation and a means of returntouseful existence. Thereisareal'needindeveloping countries, suchasthe Bahamas,toconcen trateonrehabilitative care.Itismyexperience that this area, i.e. rehabilitation and follow-up,isa critical part of the link and one whichisfrequently neglected. From a review of the statistics,itisclear that traumainthe Bahamasisnot a recent problem,itisjust thatwehave become more acutely aware ofit.For example,in1971total deaths per 100,000 population due to injuriesinthe Bahamas was 56.3. This rose to 92.3in1973 and fell againto56.5in1976, onlytorise to 96in1980, 65in1984, and 76.7in1987. Traumaisachronic disease but, unfortunately, societies inflicted with this disease develop a tolerancetothe problem whichisthen shrouded with a certain fatalism -anacceptance of accidentsasunavoidable hazards of technological advance. This chronic disease requires constant attention, education, prevention and the concerted effort of the whole society catalyzed by the medical profession. Complacencyisone of the worst obstaclestoultimate suc cessandeveninthe Canadian context where preventionissomuch preached, I saw, two weeks before arrivinginthe Bahamas, the unnecessary death of five teenagers who crashed their carathigh speeds while unbelted. ContinUing ed ucation is the keytoprevention. I trust that the 18th Annual Scientific SessiononTrauma, held by the Medical Associa tion of the Bahamasisbut the beginning of a campaign that will make its presence felt before the turn of this century and stem the tide of this pandemic of trauma.Additionalcorrespondencemay be directedtoDr. Holness, ProfessorofNeurosurgery, Dalhousie University, Halifax, Canada.4-BAH.MED.J.-JAN.-JUNE,1990


ActivityBACTROBANis.atopicalanli-bacterialagent,activeagainslthoseorganismsresponsiblelorthemajorityofInfeclians,e.g.Staphylococcusoureu..,includingmethicillinresistantstrains,otherandstreptococcI_itisalsooctive01cancenlrotiomallainableontheGrom.negativeskinpathogenssuchascoliandProteusspp.IndlcotlonsBacterialinfeelions,e.g.impeti,go, folliculitisandfurunculosis.DosageandAdministrationAdultsandchildren:BACTROBAN..houldbeapplit:dtotheaffecredoreaup10thrcctimes daily, forup1010doys.PrecautionsAvoidcontactof BACTROBANointmenrwiththeeyes. Use BACTROBAN withcautioninpatienhwilhmoderaleorsevererenolimpairment.UseInPregnancy:Thereisinadequateevidenceofsafelytorecommendtheu..eofBACTROBANduringpregnoncy.for opThalmicorintra-nasaluse.Slde-eHeclSSomeminorlocalisedeffechsuchas.burning,stinginganditchinghavebeenreported.StorageBACTROBANshouldbestoredatroomtemperature(below25C).Notallpresentationsoreavailableineverycountry. Furtherinlormationisavailableonrequest.BACTROBANisatrademark.SBSmlthKI,ne BeechamRef.,ence.lContemporaryDermatology,1987,112132.2.Prae.Inl.Symp. onBoclroban,EllcerptoMedica.1984.1903IntJDerm"1987.26!71:472. 4CurroTher.hp,,1987,4111J:11.45. f>roc.lnl. Symp on Boerfabon, EllCetp1aMedico,1984,141 6.Roy,SocMedInt,CongandSymp80,173BAH. MED.J.-JAN-JUNE,1990-5


TRAU MASYSTEMSThe Dade County Experience'Dr.Serardo501/11':'One of the basic concepts of trauma managementisthat a major trauma victim has a better chance of survivalina city with a trauma system where the injured person wouldbetransported to a trauma center rather thantoa local emergency room. Several scientifically conducted studies have documented that trauma systems and trauma centres doinfact save lives. This fact has now been accepted not onlybythe medical community but alsobygovernment. Several statesinthe U.S. have already passed trauma laws and many others areinthe process of doingso.Preventablenon-eNSdeaths Year of study Total non-eNS deaths Preventable deaths n%1982 (12 months) 2465221.11986(4months)636 9.5 1986/87(4months)7057.1A preventable death study conducted by the University of Miami showed thatin1982 just over21%of the deaths which occurred from non-CNS injuries could have been prevented. Basedonthese findings a trauma network was es tablishedinDade County (Florida)in1985. lnitia'lly, seven hospitals appliedtothe state government for trauma center designation. Of these 6 were approvedaslevelIItrauma centers while one (University of Miami Jackson Memorial Medical Center) was approved as the only level I trauma center. Afteranon-site visit The Miami Children's Hospital was approved as a participating hospitalinthe Trauma Network.InDade County, pre-hospital care and transportationisprovidedbyfive well organised rescue systems which have modern rescue units with 3 fully trained paramedicsonstaff. The pre-hospital elementisvery strong. A modern state-of the-art helicopter was provided and adequately staffed. Air transportation was utilised ifitwas determined that the time for ground transportation of a trauma patienttoa Trauma centre would exceed20minutes. Initial triage criteria were similartothoserecommendedbythe American College of Surgeons. The criteria were eventually reducedinnumber from19to6 whenanevaluatory review indicated that there was a significant degree of over-triaging of trauma patients. Thisishowevernoindication that patientsinneed of trauma services were missed.Inthe first 12 months of operation8891patients were transported to trauma centres under the Triage guidelines. With the revision of criteria, a total of 11,479 patients were transported to the trauma centres between November 1986 and Sep tember 1988. There were 824 patients who did not meet the trauma criteria but were still transported to the trauma centres after being refusedbynon-trauma hospitals. Initially the system functioned very well. The seven trauma centres and the paediatric referral centre wereallre ceiving patients and both air and ground transportation systems were functioningasper established protocols. The Medical Advisory Committee which developed the trauma triage criteria, reviewed medical issuesandappointed quality assurance subcommittees, met every month. There was excellent participationanduse of statistical data from the Trau ma registry. By 1987 howeveralllevelIITrauma Centers opted out of the trauma network. The Medical Advisory Com mittee and the quality assurance subcommittees too ceased function.Atpresent therefore, thereisonly one verified trauma centre providing services-UM/JacksonMemorial Medical Center and one trauma referrallcentre Miami Chil dren's Hospital. The County government has officially established a new Trauma Advisory Committee and a Trauma agency to implement the recommendations of the Advisory Committee and the policies of the State government, has been created.Inreviewing the whole trauma system, several problems were identified. Among them were:*medical malpractice suits -this was clearly a major physician concern. Though there wasnofirm data availabletosupportitortorejectit,the worry was that indigent patientsina trauma setting were more likely to sue. Some hospitals administrators stated that a major reason for the participating hospital's withdrawal from the system was the difficultyinfinding physician specialists willingtoprovide trauma care under such circum stances.*uncompensated care -although physiciansandhospitals provided care to the patient regardless of the patient's abilitytopay,itsoon became apparent that uncompensated care had a negative impactonthe eco nomic well-being of the institutions which provided the care.6-BAH.MED.J.-JAN.-JUNE,1990


Itwas generally felt that adequate compensation for patient careandreasonable malpractice premiums wouldresultinanimprovementinthe availability of hospitaltrauma care. With the withdrawal of the level1,1trauma centres from the trauma system the number of trauma patients trans ported has increased tremendously. This overwhelming loadhashada significant negative impactonoverall patient care function. Elective surgical procedures have been cancelled, non life threatening injuries e.g. open fractures have had longer waiting periods and patientsinneed of critical' care have hadtowaitinthe emergency care centre, operating room orinthe recovery room until' a criticall care bed was available. At present UM/Jackson Memorial Medical Centerisproviding care for over90%of the major trauma victimsinDade County.Itismore than apparent that the administrative, medical and nursing staff members arewil1lingto continuetodo so. To improve care however there are certain situations which need attention. Dade County needsatleast 2 ad ditional trauma centres, one locatedinthe northandthe otherinthe south. UM/JMMC needs aseparate trauma centre building. New strategies shouldbedevelopedtoattract nursestostaff the new units like the step-down critical care units openedatJMH for the care of the critically injured patients. Significant changes havetooccur with respecttomal practice, uncompensated care and automobile insurance. The air rescue system needs support starting with the acquisi tion of a second helicopter. The trauma system under the present conditionsinDade County will not work without the air rescue system.Additionalcorrespondencemay be directedtoDr. Gomez, Associate ProfessorofSurgery, UniversityofMiamiSchoolofMedicine, Miami, Florida.AirAmbulanceProfessionals,Inc."FlyintheAirwithProfessionalswhocare"F.A.A.Certified!FloridaStateLicense#007/MedicallyInsured 24Hour World Wide Service ImmediateResponse CoordinatedBedsidetoBedside Transport LearJetsandPressurized Twin Engine Aircrafts305-491-0555International (call collect) Certified Advanced CardiacLifeSupport ICUICCUequippedaircraft Critical Care/TraumaSpecialist A.C.L.S.CertifiedAeromedicalStaffFAX 491-6114FORT LAUDERDALE EXECUTIVE AIRPORT 1575WESTCOMMERCIALBLVD. HANGAR 36B FORT LAUDERDALE, FLORIDA 33309BAH. MED.J.-JAN-JUNE,1990-7


CHILDHOODPNEUMONIA'Dr.:li1/01/.'"'Dr.Josc(olaco,'[Jr."','cJlillc'Ral1lclial/c!cr,'Dr. 'I'atrick'Robcr(.\,'Dr.'l'crc;1'I11.1fc.\'cilwHI 'Dr. 'Palll'Robcr(.\AbstractThe medicalrecordsof100children(mean age 1.8 years)consecutivelyadmittedtothe wardwithadiagnosisofbronchopneumonia,are reviewed. All' the patients had afullbloodwork-upandchestx-rays on admission. All patients were commenced andcontinuedon antibiotics95% intravenously. 55%ofthe totalleukocytecountsand 56%ofthechestx-rays werenormalwhile91%ofthebloodcultureswere sterile. The managementofrespiratoryinfectionsneeds review.Bloodculturesandchestx-rays areimportantdiagnostictoolswhichshouldbeusedjudiciously.IntroductionBronchopneumoniaisone of the most common causes of morbidityandmortality among infants and young chil dren the world over. A mean of 727 cases of bronchopneumonia are admitted every yeartothe Children's Ward of the Princess Margaret Hospital, Nassau. Since 1987, however, therehasbeen a significant decline(p<0.05)inthe number of cases of this condition which were admittedtothe ward. It is well known that the vast majority of cases of bronchopneumonia are viralinorigin. Thereisa small percentage of cases which have primary bacterial pneumonia and avar,iablenumber which develop secondary bacterial infection. The most common organisms involvedinbacterial pneumonias areS.pneumoniae,H.influenzaeandS.aureus.Ingeneral, bacterial pneunlonias are more common among children who are malnourishedandamong those who come from poor and overcrowded situations.MaterialandMethodsThe medical records of a 100 consecutive admissions or bronchopneumonia admitted to the Children's Ward of the Princess Margaret Hospital, Nassau (population 150,000) from January1,1989onward!were reviewed. The records of12patients were incomplete, in that the results of blood studies requested were not documented.Results Total numberofpatients n=100, M55, F45, Mean-age 1.8 years,SO1.1,SEM 0.1. The results of blood investigations are listedintables 1 and2.55% of the total leucocyte counts were within normal limits.In28 patients the differential leucocyte counts were in complete. Only9.1% of the blood cultures were positive.Table1.Table 2 Totalleucocytecountper c.mmBloodCulturesn=88 n=88n%n%Sterile 8091<5000 4 5S.pneumoniae 5000-11000 4855S.aureus 3 3 12000-190002629H. influenzae 4 5>200001011The reasons for requesting chest x-rays and the results of the chest x-rays are listedintable 3and4.In52% of the patients the chest x-ray was requested routinely andin70% the chest x-ray diagnosis did not resultina changeintreatment.Table3 ReasonsforrequestingChest X-Rayn=100RoutineDiagnosisindoubtNoimprovementdespitetherapyWorseningofrespiratorystatus8-BAH.MEO,J.-JAN.-JUNE,199052402 6Table 4 Chest X-Ray Resultsn==100 NormalBilat-BronchopneumoniaRLLpneumoniaRULpneumoniaRMLpneumoniaLULpneumoniaLLLpneumonia5613128 6 32


Associated illnesses seenin31%of the patients included Gastroentenitis, Otitis MediaandAIDS. All mantoux tests doneonthese patients were negative. 26 of these patientshadhistory of previous admissiontothe ward, for bronchopneumonia. Tables 5 and 6 list the antibiotics usedinthe treatment of the patients and also the duration of stayinthe hospital.Inthe treatment of these patientsallantibiotics except erythromycin were administered intravenously.Table 5 Table 6AntibioticTreatmentAmpicillin/AmoxycillinCombinationAmpicillin/Chloramphenicol/CefotaximeErythromycinCefotaxime71% 11%4%2%<1day1-5days6-13days>14daysDurationofHospitalization 4%14% 52% 18%The mean duration of stayinthe hospital was 6.2 days and there was no mortalityinthis group.DiscussionMost of the serious pulmonary infectionsinchildren which merit admissiontothe ward involve the smaller airways, namely the terminal respiratory bronchioles and surrounding alveoli. These infections are usually viralinorigin. Howev er, there are cases which are bacterial'inetiology and which are responsible for the significant morbidity of this disease.Fig. 1BLOOD CULTURESFig. 2CHEST X-RAY FINDINGS Normal (56%)-I1'-R.UpperLobe(8%)L.Lower(2%) ,'.L.UpperLobe (3%)"...R.MiddleLobe(6%) Bilateral (13%)"R.LowerLobe..,;:tI',:lr'"T"rf'.I':'."':,";,:':'.:....STAPHYLOCOCCUS (3%)-,+.+--r-='S.PNEUMONIAE(1%).',H.INFLUENZAE (5%)This study reveals that 56% of children admitted for bronchopneumonia did not have radiological evidence of bron chopneumonia. All these patientshadchest xrays requested routinelyatpoint of admission. Radiation has its own side effects anditisour opinion that the useotthis important diagnostic tool mustbejudicious. Early viral infections might present with shiftstothe left as would bacterial infections.Inthis respect theFBCis only of partial useindifferentiating between bacterial and viral illnesses. This study identified that 22% of the differential WBC counts were incomplete. Ob viously, close attention needstobepaidtothis aspect of the workup.That only 9% of blood cultures were positive could mean that the culture technique merits attentionorthat only 9% of these patients had bacteremia. The routine availability of nasopharyngeal cultures for viruses would have allowedustoreserve blood cultures for patientsinwhom bacterial pathology was suspected. Retrospectively,itisdifficult to commentonthe blanket use of antibioticsinthis group of patients. Criteria, howev er. need to be established which help decide which patients should be continuedonantibiotics and which are held-off antibiotics and closely monitored for possible recommencement if and when necessary.TheauthorswouldliketothankMrs. Hannah Gray and Ms. Gina Dorsettofthe HealthinformationUnit,MinistryofHealth,fortheirassistance.BAH. MED.J.-JAN-JUNE,1990-9


SURGICALSHOWorkload'Dr'/PilliIlIlISOIl("hellIntroductionASeniorHouseOfficer(SHO)isanImportantlinkin the teamofphysicianswhichnormallyconsistsofConsultant,Senior Registrar/ Registrar, SHO and Intern. ThedutiesofthesurgicalSHOincludedirectsupervisionofan intern, ward work,attendingsurgicaloutpatientandspecialityclinics,assistingintheoperatingtheatre and being on-callforemergencies. The on-calldaybeginsat9 a.m. on agivendayandendsat 9 a.m. thefollowingday.Duringthisperiodoftimethe SHOisresponsibleforprovidingemergencycoverforallthesurgicalwards(private, male, female and paediatric) General Practice Clinic,Accidentsand Emergency Department and the Intensive Care Unit. The SHOisalsorequiredtoattendtohisregular ward and operating theatredutiesand attend cardiac arrestcodesin thehospitalwhenoncall. Muchattentioninresidencyprogramsisbeingfocusedupontheworkloadthat is carriedbytheresidencystaff. Thelongworkinghours(SHOswork70hoursormoreper week) and the resultantstressand sleepdeprivationareknowntohave adetrimentaleffectonaphysician'sclinicaljudgement.Equallyimportantis thestrongnegativeimpactthisenormousworkloadhas onthepersonal health andfamilylifeofthephysician.TheaimofthispaperistostudytheemergencyworkloadofthesurgicalSHO at the Princess Margaret Hospital (PMH) in Nassau. Materials andMethodsEvery single call/referral received bymevia the bleeper when on emergency call was recorded in a diary, as the call was received.Inemergen cy situations the recording was done after the emergencies were attendedto.The information collected included the area the referral was received from, reason and time referral and whether admission and surgery was required. The study includes all duty days between October 1 and December31,1989.ResultsThe total number of calls received Total numberofadmissionstowards 300 (mean 14 per duty day) 108 (mean 5 per duty day) Area from which referrals were received Accident and Emergency Department Other areas-192(64%) 108 (36%)Fig. 1: Reasonsforreferrals/Calls Fig. 2: ReferralsfromAccidentand Emergency DepartmentTolal n=300 Othera14%UrologyENT'\/\Neuroaurgery,../Orthopaedlca-31-/0n= 192General Surgery41%OrtholOperalor Warda CardiacNeuro-cod...SurgeryNeuroaurgery'Urologyo30.!!20ii"0;,! 10Table 1 Table 2TimeofCall vs. Number NumberofCalls Weekday vs. WeekendTime9 a.m.-5 p.m. Total No.ofCalls154 (51%)Days Average No.ofCalls/day Mon.-Thu.13.85 p.m.-9 a.m.146 (49%)p>0.05Fri., Sat., Sun.,Holidays14.1p>0.051Q-BAH.MED.J.-JAN.-JUNE,1990


Conclusions and RecommendationsThis study shows that the workload on a surgical SHO is indeed heavy. The vast majority of timeisspentondirect patient care. The majority of the referrals come from the Accident and Emergency Department. The on call work-load between the hours of 9 a.m. and 5 p.m.issimilar to that from 5 p.m. to 9 a.m. This heavyworkload has left very little time for academic sessions. The SHO on-call should be relieved of routine non-emergency work for that day. There should be separate cardiac arrest code teams. Thereisa strong need for surgical speciality on-call teams to deal with the extraordinary amount of trauma seen. The surgical department needs additional residentstaff to ensure that timeisavailable for better training. On going training sessions would also benefit Emergency Room physicians.LETUSMANAGEALLYOURINSURANCENEEDS...PERSONALANDCOMMERCIAL,INCLUDINGHEALTHANDLIFE.1...._....AGENTSFOR:@ALLiANCEASSURANCECOMPANYLTD.ASSICURAZIONIGENERAL!S.pAAMERICANHOMEASSURANCECOMPANY.+"BLUECROSS&BLUESHIELDofTHEEASTERNCARIBBEAN.INSURANCEMANAGEMENT(BAHAMAS)LIMITED.I I,.IIIIII,1",1iIIIIIIII--NASSAU OFFICEP.O. BOX SS-6283 COLLINS AVENUE TELEPHONE (809) 325-2831 TELEX: INSURMAN 20456FAX:323-6520FREEPORT OFFICEP.O.BOX F-2541 PIONEERSWAYTELEPHONE: (809) 352-7421 TELEX: SUNALLCO 30061FAX:352-2857IIBAH. MED.J.-JAN-JUNE,1990-11


EMERGENCYROOMProfile of Patient Flow'Dr,SipaStUIl/aramIIlld'Dr,_Yicfio/lls.1IcpbllmAbstractThecasenotesof1274patientsregisteredintheEmergencyRoomare reviewed.Thevastmajority933 (73%)weretreatedanddischargedandonly151 (12%) neededadmissiontotheward.Amean182patientswereseeneachday.Nearly50%ofthepatientswerechildren.Forapopulationof150,000thenumberofpersonswhoattendtheemergencyroomisveryhigh.Thesituationwouldbenefitfromincreasedemergencyroomspaceandstaff,increasedtrainingforstaffandpublichealtheducationwithemphasisonprevention.MaterialandMethodsThe case notes of 1274 patients who were consecutively registeredatthe Accident and Emergency iJepartment of the Princess Margaret Hospital, Nassau from October1,1989 to October8,1989, were reviewed,ResultsFig.1Fig.2TotalInflowPatternTotal-1274 Male/Female Ratio (Treated)10IleoMale597ATreated&DischargedC-DeadBodiesB-WalkedawayD-Admittedfemale487The daily flow of patients into the departmentisillustratedinfig.3.The average number of patients seen per day was 182. The number of patients seenonthe weekend was higher thanthe number seenonweekdays but this was not significant(p">0.05). The composite flow by the hourisseeninfig.4.The greatest number of patients were seeninthe hours between8 a.m. and12midnight.250 .---______.Fig.3TimeofdayoL...I..----L-1-L-L-l.-..L...JL.J..-'-..L......J----L-L-.L...1-.L-'----.L...1-.L-L..J123456789101112131415161718192021222324Fig. 4CompositeHourlyInflow(SundaythroSaturday)100/',80I \',---I'\60\t........--".,\/\,40I20\/Sat Fri Wed ThuSunMon TueDailyFlowOfPatientsPAT IE N TSNearly 50% of the patients wereinthe paediatric age group (fig.5)with the vast majority of these being less than 5 years of age. When the actual number of patients seenbyeach emergency room physician was calculated (fig. 6), a variation was noted. While four physicians were treatinganaverage of 4.75 patients per hour, six of their colleagues were able to treat a mean of 1.85 patients per hour.12-BAH.MED.J.-JAN.-JUNE,1990


0-5 6-10 11-1516-20 21-2526-30 31-3536-45 46-55 56+AgeGroup5001400PAT300IEN 200TS100oFig. 5 AgeDistributionPAT IE NTSFig. 6 No.ofpatients seen perHour8,-......:....-::.--)765 4 32oDr. A Dr.B Dr.CDr.D Dr.E Dr.F Dr.G Dr.HDr.1Dr.JThe waiting periodandthe number of patients who hadtowait for that amount of timeandalso the cases whichhadprolonged waits are seeninfigs.7and8.The vast majority of patients(71%)were treated within 2 hours of their arrival into the department. Life threatening emergencies were given their usual priority.0-11-2 2-334-5 5-6 6-77-8 8+HoursPAT IENTS500,-_oFig. 7 Mean Waiting Period Fig. 8 Some LongWaitsRooma4Hours-9 lacerations 3 fractures 1 myositis 1 human bite 1 dog bite 5Hours-11lacerations 1P.V.Bleed 1 hematoma 2 fractures 2 nail sticks 1 tonsillitis 6Hours-3 lacerations 1 contusion 1 abscess 1 cellulitis 7Hours-1 laceration 1 fracture 1 cut tendon 8Hours-1 lacerationDiscussionThe number of patients who areinneed of emergency treatmentisvery high for a population of150,000.The projection from thisisthat approximately67,000visits would have been madetothe emergency room (ER)in1989. This mightbeinterpretedintwo ways. Either there are much too many persons gettingillor individuals who do not need emergency care turnupinthe department and then havetobeseen. Thereisalso the question of delayingettingtosee the physician. There are several reasons why this delay occurs: theERisbusy, theERphysicianisbusy, the cubicles are occupiedbypatients waitingtobeseen by the second-on eall from the ward (he/sheisnormally very busy), some cases take longer than others, some physicians are more laboured than others andERstaff fatigue (this usually setsinafter5-6hours of non-stop action). The Department would definitely benefit from more staffandspace. This, one hastoacceptismore easily said than feasible. However, the possibility of securing the sessional services of experienced physiciansisworth exploring.Itbeing implementedinother areas of the Caribbean and appears to work well. The staff would benefit from regular inser vice training programs. The deployment of staffinsuch a manner that a new or less experienced physician works along with a more experienced physician would increase the confidence of the young physician and thereby increase his speed. The element of fatigueisanimportant one and canbeovercomebyrestructuring of the working scheduleinsuch a way that the existing number of hours are workedin6 hour shifts.Inany event it appears that thereisneed of increased publ'ic health education.Ifillnesses are treated early, the majority would not need emergency room care. The message of prevention apparently too, needs reinforcement.BAH. MED.J.-JAN-JUNE,1990-13


SICKLECELLDISEASE-A Studyof60Cases'TllIll'Ricf;ardsoll,'Dr,Stt'lIt'Locf;all,'Dr,Jo.'t'Colacoalld'Dr,'Palrick'Roberl.'AbstractThe notesof60 patients consecutively admittedforsicklecell disease related problems are reviewed. The mean age at admission was 13.3 years. Female patientadmissionsweresignificantlygreater(p<0.05)than male.SISand SISF were thetwomostcommonhaemoglobinsidentified. Painfulcriseswas themostcommonassociated illness. Noneofthe blood cul:ures yieldedpositiveresults. Intravenousfluidswere used on 71%ofpatients andantibioticsin85%. The mean lengthofstay in hospital was 8 days. Culture techniques andantibioticregi men require review and standardization.AimTo study the morbidityinpatients with sickle cell disease with specific referencetopatients who are admitted to the Princess Margaret Hospital, Nassau.Material and Methods The notes of 60 patients of sickle cell disease who were admittedtothehospital consecutively are reviewed. The period of these admissions was from January 1987toJune 1988. Statistical analysis of the data obtainedisbasedonSwinscow (1985),ResultsThe total number of patients reviewedis60.Male 25. Female 35 M:F ratiointhe population of The Bahamas-J1 :1.009. The mean age at admission was 13.3 years,SD10.1, SEM 1.3 (table1).Table 1 Table 2 Age atAdmissiontoWard Reasonforadmissionn % n % <1 year 0 0 Painfulcrises4168 1 yr.-4 yrs.1525Nephropathy 4 7 5 yrs.-12 yrs.2237 Sequestration 3 5 13 yrs.-21 yrs. 4 6 Haemolytic crises 2322 yrs.-34 yrs.1932Aplastic crises 23>35 years 0 0 Others 814The most common cause for admission was painful crises (Table 2). 28 (47%) patients were afebrile at admission, while 6 (10%) had a fever of1'02F or greater. 20 (33%) patients had hepatomegaly while10(16%) had splenomegaly.In18patients (30%)anejection systolic murmur was audible at the apex.Table 3 Table 4 Associated Problems Total Leucocytecountper c.mm n % n % Respiratoryinfections1525>12000 4270Urinarytractinfections1017>15000 3863Legulcers5 8>200002237The associatedproblems diagnosedatadmission are listedintable3.Respiratory infections were notedtobe the most common (15%). The mean haemogl'obin level was 7.6 Gms% with normal MCHC and elevated WBCin42 (70%) of the patients. Vide table4.14-BAH.MED.J.-JAN.-JUNE,1990


28patients (47%) had haemoglobin SIS,21patients (35%) S/SF while 2 patients (3%)l1adSIC.Haemoglobin electrophoresis results were not yet reportedin9 patients (15%). The results of the septic screen are recordedintable5.Significantly, none of the blood cultures yielded any posi tive results. Over a third of the urine samples grewE.Coli.Itwas not clear from the notesifany of the samples wereTable 5 Table 6 Septic screenAntibioticTherapyCulturennumber+ve%+ven %Blood440 0Ampicillin2237Urine2610 38Penicillin0 8Stool60 0Penicillin + Gentamycin58CSF40 0Flagyl + Gentamycin58ThroatSwab180 0NafcillinChloramphenicol58Cefotaxime58Augmentin35obtained by a suprapubic tap orbya mid-stream catch andifthe culture procedure was performed within 30 minutes of the sample being obtained. Antibiotics, mainly intravenous were usedin82% of the patients. Ampicil,lin was the most common antibiotic used. The others are listedintable6.Intravenous fluid was usedin71%of patients. The average length of hospitalization was 8 daysSO4.2, SEM 5.4. There was no mortalityinthis group.DiscussionSickle cell diseaseisa major cause of morbidityinThe Bahamas, the Caribbean andinfactinmany parts of the world. With the advent of AIDS, however, thereisa danger that the sickle cell research mightberelegated to a second ary position. This study indicates that patients with this disease are spending extended periods of timeinhospital and receiving broad spectrum antibiotics while their septic screens yield precious little.Itisperhaps that the septic screen techniques and the antibiotic regimen might benem from review and standardization.TinaRichardsonisa medicalstudentat TheUniversityofLeicester Medical School, Leicester, England.Thiswas thesecondofhertwoprojectswhichsheundertookwhileon an elective in The Bahamas.EXODERILatopicalantimycotictungicidalactivilyComposlllon,IgcontainsNaltitineHydrochlollde10mgPIopertles,Nallitineis anewtopicalantimycoticItacts-inverylowconcenlrations-pnmanlyfungiCidalagainstdermatophytesandfungistaticagainstCandidaspecIes.Exoderilhasalocalbatericidalellectongram-posItiveandgram-negativebacteriaIndications,I)Alldermatophyteinfectionsottheskinanditsappendages(hair.nOli)duetoTrichophytonspecies.MIcrosporumspecies.Epidermophytont1occosum. 2)SuperticialcandidiaSIS. 3)Onychomycosis4) Pitynasis verSicolorTheseindIcationsIncluderntertriginousmycoses(submammary.rnterdlgltal.rntergluteol.rnguinal)Applicationanddosage,1)SkinmlectJOns Unlessotherwiseinstructedbythedoctor.EXODFRIL"ISthrnlyappliedoncedOlly(atbestbeloreretillng)totheallectedskinareaandgentlyrubbed10TheentireviSIblyallectedsurfaceandalsoanapproximatelyonelOch WIdemargrn01clinIcallyhealthy......__.....skinroundthelesionmustbetreatedateachapplicationIn,.,._ casesotintertrigrnousmycosesitisollenadVIsabletoplacea StllP01gauze.especiallyovernight.inbetweentheskinlolds2)NailmleclionsTheinlectednallisclippedasshortaspOSSIble EXODERIL'ISappliedoncedailytotheinfectednOllandrubbed10Itisadvisabletocoverthenllli'::ilhanocclusivebandage3)GeneralrecommendatIons:Beloreapplicationtheatlectedskinareaornailshouldbecleanedwilhacottonswabandwarmwaterandthoroughlydried.Reliableandsullicientlylongapptication01EXODERILisimporlanlloratullsuccessotIhetreatment.Topreventrelapses.Ireatmentshouldbecontinuedtorabout2weeksbeyonddisappearance01allsignsollhedisease.Thedurationollherapyvaries.Itisusuallyindermatophyteinfections2-4weeks.inseverecases4-8weeks.insuperticialcandidiasis4weeks.inonychomyCOSIsupto 6months.inpityriasisverSicolor 2weeksTolerance,EXODERIL" isexcellenllytolerated.Alterlopicalapplicationnosystemicellectsaretobeallected.Contraindica-tion,HypersensltivllyagainstEXODERIL"oranyadjuvantsubstanceolthecompoundPIecautions,EXODERIL"cream/geli'lortopicaluseonly.Itshouldnotbeappliedtoacuteintlamedoropenlesions EXODERIL"isnottobeusedinophthalmolog,Interactions,UnknownSidee!tects,Inrarecasesmildandlullyreversiblelocalirritationsuchasburninganddrynessmaybeobserved.Discontinuationoltreatmenlisonlyrarelynecessary.PIesentatlon,EXODERlL"cream.EXODERIL"gel.tubesotl5gand30g.jarsot200gStoremedicinesoutofthereachofchildrent BIOCHEMIEGesellschallm.b.H .Wien/Vienna/Vienne/Viena-Austria/Autriche.1235Wien.BrunnerSlrasse 59BAH. MED.J.-JAN-JUNE,1990-15


ATTEMPTEDSUICIDE,\/r,\.('tlro/l'lI'Rober/.;tllld'/Jr.,Yd,\oll('Itlrk!'AbstractThenotesof98consecutivepatientswhoattemptedsuicidearereviewed.Themajority(66%)werefemaleandfromtheyoungadult(11-30 years)group.Prescriptionmedicationwasthemostcommonvehicleutilisedfortheattemptanddepressionwasthemostcommonassociatedillness.Thisisanunusuallylargenumberofcasesforsuchasmallpopulation.Specialattentionneedstobepaidtotheyoungfemalepatientwithrecurrentepisodesofdepression.Thereisalsoaneedtoreducestressandtoreturntothefamilylife.MaterialandMethodsThe case notes of98consecutive patients who had attempted suicide are reviewed. This is the total number of cases of attempted suicide seen at Doctors Hospital, Princess Margaret Hospital and the Community Mental Health Clinic from JanuarytoDecember1989.Allthe patients were from the island of New Providence (NP) which has a population of about150,000.ResultsTotalnumberofpatients98 Male 33 Female 65PopulationM:Fratio1 :1.009(p<0.05)AgedistributionMethodappliedAssociatedillnessesPsychiatricillnessesagegroup11-20years2130years3140years4150years51-60years age unrecorded medication self-inflicted injury jumping off building not documentedprescriptiondrugsand14 OTCs)psychiatric non-psychiatric none depression drug dependence schizophrenia not recordedM6126414F32238 1 168 642045not recorded not available325 843Total38 35 145 24DiscussionThe casesinthis study are not necessarily all the cases of attempted suicide for 1989. Cases presenting at other institutions andtoprivate practitioners' offices were unavailable for the study and thuswewere unabletodetermine the incidence of attempted suicidesinthe communityasa whole.Itiswell documented that a significant number of at tempted suicides present initially to family practitioners who may not seek further referral or assessment. Studies show that 75% of patients who subsequently committed suicide had seena physician within one month of their death, with psychosomatic symptoms associated with depression. This study reveals several important indicators relevant to the suicidal attempts. Over 66% of the attempts were made by females, of which 85% wereinthe 1i-30 years of age group. Medicaiion was the vehicle of choicein69%.1,1thIS,prescription drugs were chosenbythe vast majority (79%). Data relevant10associated illnesses was not availablein43% of the patients. Depression was the most common illness presentin71%of patientsinwhom there was re cord of associated illness. Today, physicians encounteranincreasing number of stress related illnesses. Physicians needtobemore vigilantinthe detection of recurrent cases of depression, which may leadtosuicide attempts. The social ills arising from drug addiction, unemployment, inadequate child rearing practices and the disruption of traditionalfamily unit are becoming more widespreadinour island community. Suicidal attempts mustbetaken seriousiy. and managed promptly and ap propriately.Ifiqnored, the end couldbefatal.H)--BAH,MED ...i.-JAN.-JUNE,1990


BAHAMASDR'UGAGENCYBetween8th&9thTerrace 114 CollinsAve.Phone:325-6069 326-6848...:::-I.,KENDALL-CURITYSterileCottonBallAdhesiveTapeEyePadsGauzePadsStretchGauzePadsTelfaPadsAlcoholPrepDermassageLotionDisposIncontinentPantDisposUnderPadsCottonTipApplicatorsGauzeSpongesJOHNSON&JOHNSONCidex7ExamGloveGamophenSoapKYLubJellyDermicelTapeDermiclearTapeElastikonTapeNuGauzeSurgineIIFaceMaskSof-KlingBandageSof-RolCastPaddingSpecialistPlasticBandageDistributedby:BAHAMASDRUGAGENCYP.O.Box N-8316 Nassau,BahamasBAH. MED.J.-JAN-JUNE,1990-17


4$UPER$AVERPHARMACYRosettaStreet-Tel.323-8309VillageRoadShoppingCenter-Tel.393-2393P.O.BoxN-7547THEPHARMACYWhereefficientserviceisguaranteedandfriendlyserviceawaitsyouOPENEVERYDAYincludingHOLIDAYS&SUNDAYSfrom9:00am.-I0:00p.m.with COMPETENT PHARMACISTSonduty at all times willing toanswerall your medical questionsWefIllprescriptionsfromalllocaldoctorsCOME IN ANDVISITUSPHARMACISTS:MikeThompson,JonathanFrazer,LauraPrattLeonardLeadon,RobertSands&AlvaterBartlettRochelle Russell -JuniorPharmacist18-BAH.MED.J.-JAN.-JUNE,1990


,EST.1908SO,LOMON BROTHEIRSLIMITEDWHOLESALEWAREHOUSESERVINGTHEENTIREBAHAMASWholesaleGroceriesMeatsCandyPharmaceuticalProductsSouvenir&T-ShirtItemsForallyourshop needsmakeSolomon'syourone-stop-wholesaler.It'sourpleasure to serve you!INNASSAUINFREEPORTPHONE:393-4041 (13 lines)PHONE:393-4854directfor ethicaldrugorders. P.O. Box N3218 Telex: 20305 Fax: 393-4167PHONE:352-9681 P.O. Box F318 Telex: 30035 Fax: 352-5125EAST-WESTHIGHWAYINMARSHHARBOUR,PHONE: 367-2601-2ABACaP.O. Box MH563 Fax: 367-2731Call today for fast, efficient serviceandthewidestvarietyofwholesale goodsintheBahamas!6bBAH. MED.J.-JAN-JUNE,1990---19


DynaCirc@isradipineThe new first-line antihypertensiveformost ofyourpatients,mostofthe time. Effective as monotherapy. Even acrossallage groups. Excellent tolerability. Evenwhenadverse events common to antihypertensives are considered. Reassuring safety profile. No contraindications. Eveninspecial patients. Simple dosage regimen. 2.5mgb.i.d. acrossallages,allpatient types.DynaCircisradipineFormostofyourpatients.Mostofthetime.Sandoz Ltd. Basle Switzerland2o-BAH.MED.J.-JAN.-JUNE,1990


Trent 4activeingredient:PentoxifyllineIproven clinical' efficacy in periph,eralvasculardiseaseprovenclinical efficacyin,cerebrovasculardiseaseTrentalactsatthesiteofth'eproblem restores red cell deformabHity decreases blood viscosity reduces fibrinogen levels inhibits platelet aggregationTrentalimprovesthenutritivemicrocirculation,restoringpain-freemovementandmentalfunctionHoechst(BBAH. MED.J.-JAN-JUNE,1990-21


STETHOSCOPEAI:..WSLETTERFRJ\\TilEBAHAMASMEl IALJURN L.\by31.1990SMOKINGCIGARETTESN10KINGISi\FORMOFDRUGDEPENDENCEthathasbeenassociatedwithacatalogueorhealthproblems.Amongthemarecancers,coronaryheartdisease,bronchitisandemphysema,gastricandduodenalulcers,diminishedphysicalfitness,gumanddentaldiseaseandblindness.Itisgenerallysaidthatwitheverycigarettesmoked,thesmoker'slire isreducedby5minutes.Thereisalsotheproblemor'passivesmoking'.Familymembersespeciallychildrenaremorepl"OnetorespiratoryproblemsirsomeoneInthehouseholdsmokes.Thereisahigherincidenceorpneumoniaandasthma.Smokinginpregnancyisthecauseormanyroe talandneonataldeaths.Besides,achildorasmokerism(welikelytosmokeasanadultthanachildoranonsmoker.Givingupsmokingis notasdifficultasiscommonlybelieved.Over66'V<,orsmokerswhokickthehabit,dosowithease.Persuasion,however,hastobetailoredtotheindividual'spersonality.Somewouldprerertodealwiththecomplicationslaterthanbemiser"able today.Otherswouldperhapsrealisethatsmokingcausesproblemslorthemselvesand1'01'theirlovedonesandyet,lackthemotivationtotryandquit.Healtheducationhasprovidedtobeveryuserul inthesecases.The/'earejustarewwhowouldbesostubbornastototallyshutoutalladviceandevengetupsetaboutit.Manycountriesmayhaveaneconomicjustificationexcuserather,1'01'theirsortapproachonsmokingandsmokeingeneral.Thisisdespitetheostensibleconcern1'01'theenvironment.TheBahamashasnosuchproblem.Therewouldbenoincreaseinunemploymentorsignilicantshortrailinr'evenuerromtakingahealthystandonsmoking.In racttheremightbe asavingonrOJ'eignexchangeandalsoaconsiderablesavingonhealthcarecosts.Itisjustaboultimetointroducesmokefreeareasinpublicplacesandtocommenceahealtheducationprogramtodiscouragesmoking.BasedonThe Bahamas Report on Smoking,WinstonCampbell, MD PAHO (1987)andTobaccoClinical Pharmacology, Laurence DA and BennettPN(1980)GERIATRIC HOSPITALIS25TheGeriatricHospitalattheS,tndilandsRehabilitationCentre,FoxI-lillthisyearcelebratesits25thyearorsterlingservicetotheseniormembersortheCommunity.,June1990hasGeendesignatedasGeriatricIlospitalmonth.Thereareapproximately150patientsat thehospital.Thelove,care22-BAH.MED.J.-JAN.-JUNE,1990anddedicationorthe::;tafforththospitalisworthyorspecialmention.UMLIBRARYSERVICES FOR PMHThePrincessMargaretHospital(PMH)inNassauhasjoinedtheLouisCalderMemorialLiG",lI)'ortheUniversityor,"Y\iamiSchoolori'vledicintasaninstitutionalmemGer.Nlakingthisannouncement,thePMHadministrator;\lr.StephenCampionsaidthata rull ,"angeorproressionallibraryserviceswouldnowbeavailabletosupportpatientcareandcontinuingeducationactivities.Comprehensiveinrormationservices,rreeorcostarcnowavailabletoPiV\Hstafr.Itishopedthatever)'attemptwill bemadetotakeadvantageortheseservicesonaregularbasis.ROBINISNEWMABCHIEFDr.RobinRobertsisthenewMABPresident.ThisyounganddynamicurologistwasthenaturalchoicearterthelinerunasVicePresidentrorthelasttwoyears.RobinhasbeeninstrumentalintheacademicturnthattheN\ABhastakenoverthelasttwoyears.TheregularacademicmeetingsandtheweilorganizedconrerencesareatestamenttohiscommitmenttoexcellencethroughContinuingl'vleclicalEducation(Ci'vlE).Dr.RobertswillreceivestrongsupportrromDr.HuGertMinnis(Vice-Pr"esident),Dr.ElizabethDar'ville(Secretary),Dr.WilliamsonChea(Treasurer),Dr.AgretaEneas(Councillor),Dr./\nthonyNembhard(CouncilloJ")andDr.KirtlandCulmer(PastPresident).DR.SOARESTOJOINBONSECOURDr.PrakashSoareswhohasservedforthelast12yearsasaSeniorRegistrarinMedicineatPMHwillsoonbejoiningthemedicalstaffatBonSecourHospitalinDetroit.ThequietandunassumingDr.Soareshasmadeat,"emendouscontributiontothedeliver.)'01'healthcareinthefbhamasandeamedthereputationorbeingone01'thefinestphysiciansintheland.\Vewishhimandhis lillllil.)' alltheverybest intheI'uture.DR.OFOSU-BARKOFORSANJUANDr.KennethOfosu-Barko,theJ'v\edicalOnicer01'HealthforN.P.hasacceptedanolferI'romHarvardUniversity.HejoinstheirteamasaprojectepidemiologistinSan,Juan,PuertoRico.Dr.BarkoservedIIItheBahamassince1984.Theenergy,dynamismandcomputerexpt'rtiseorthiskeenandrorthrightphysicianwill bemissed.GoodlucktoyouandtheI'amily,Ken.CDDWORKSHOPTheControlorDiarrhoealDisease(CDD)Program-OahamasheldaSkills\Vorbhopin\-\arch1990 atPNUI.Twentyphysiciansandnursesrromthevarioussectorsorthehealthca,-esystemattendedtheworkshopwhichwas


jointlysponsoredbytheMinistryofHealthandPAHO.TheCOOProgramisnowsettingitssightsonestablishingOiar'rhoealTrainingUnits(OTU)atPMHandattheRandinFreeport.CONFERENCE '91ThenextMABconferencewillfeature'AdvancesinHealthCare'.Arrangementsareinprogressfor it to be held fromJanuary30,1991-February3, 1991attheCrystal Pal aceHotel,CableBeach.Forfurtherdetails pleasecontactDr.RobinRobertsorDr.AgretaEneas,P.O.Box N-4477,Nassau,Bahamas.CCMRC GRANTSTheCommonwealthCaribbeanMedicalResearchCouncilhasannouncedtheavailabilityoftwotypesofresearchgrants-theCCMRCgrantworthUS$5000.00andthespecialPAHOgrantworthUS$15,000.Furtherdetailsareavailable FromtheCCMRC.Acopy01'theannouncementISwithDr.RobinRoberts,President-MAB.Attendance'atsome health facilities inNewProvidence(1988)-population150,000SpecialtyClinics(PMH)50,000AmbulatoryClinics(PMH)120,000EmergencyRoom(PMH)60,000CommunityClinics55,000Inpatientbed-days(PMH)88,000SCBUbed-days(PMH)9,000Allfiguresareroundedanddonotincludevisitsmadetoprivateofficesofphysiciansortoprivateclinicsorhospitals.PHYSICIANS AT RISKDr.MervilleVincentwritesIntheAnnalsofTheRoyal College01'PhysiciansandSurgeonsofCanada(Jan.1990)that'toomanyphysiciansendup withproblemssuchas: fatigue,exhaustionandcynicism depression,alcoholanddmgdependenceWE CAN DO IT ALL maritalandfamilydysfunctionordivorce'ItisimportantForphysicianstobeawareoftheseproblemsandtakethenecessaryprophylacticmeasures.Certainlyiatrogeniccomplicationscanandshouldbeavoided.EMERGENCYDELIVE,RY-OURSPE,CIALTYBUSINESSFORMS PEGBOARDFORMSCOMPUTERFORMS WEDDING INV,ITATIONSCHRISTMAS CARDSOFFICE FURNITURELABELS RI,BBONSB'USINESS GIFTS-DATAPROMOTIONSCONVENTIONS 138 MACKlEY ST.PHONE3913-5707BAH. MED.J.-JAN-JUNE,1990-23


RECENTTRENDSINBLOODBANKING'[Jr.OIl'IISII."1.'[Jill/IiThe management of safe blood products and the use of blood whichisfree from contamination by viruses, includ ing HepatitisBandHIVisof growing importance. This concernisreflectedinthe rapid organisation of the national AIDS programinThe Bahamas and several other countries. Since 1984 the threat presentedbyAIDS has been recognized by many countries, makingitimperative to develop and systematically use sensitive methods for the detection of the antibodytothe Human Immunodeficiency Virus (HIV), its causative agent among blood donors, blood batches and blood products. During this period, the practical health significance of transfusion induced Non-A Non-B Hepatitis has been increasingly realised, leading some countriestoimplement additional blood screening procedures suchascorzyme for Hepatitis core antibodyandalanine transferase, ALT. Despite a program to screen for Hepatitis B virusinblood donors since 1970, and the development of improved sensitivity tests for Hepatitis Bsurface antigen (HBsAg)in1975, cases of transfusion associated Hepatitis (TAH) contin ue to be reported. This form of Hepatitis, knownasNon-A, Non-B (NANBH)ischaracterisedbyanacute illness with classical hepatitis symptoms, and elevated liver enzymes (ALT levels 2.5 times normal). These tests referred to as sur rogate testing program help indirectlytoexclude NANBH. Recently NANBH has been classifiedasHepatitis C (HCV). Characterisation of HCV beganin1984 at the CDC (Centre for Disease Control, Atlanta). Currentlyanantibody assay for HCV has been developedtodetect HCV (NANBH) which will soon replace the surrogate testing program. The problemisthat the current HCV antibody assay fails to detect 100% of NANBH and this has toberesolved before this new assayisaddedtothe battery of screening tests doneinthe blood banking practicestoensure safe bloodtothe community. Following the introduction of HIV testingasa screening procedure, blood banksinsome countries have initiated the screening forHTLV-1.HTLV-Iisa retrovirus similar toHIV.HTLV-Iisassociated with two distinct diseases ATLL (Adult T-Cell Leukemia/Lymphoma) and TSP (Tropical Spastic Paraparesis). Epidemiological studies indicate that indi viduals most likely to be at risk for HTLV-I infection are persons from HTLV-I endemic areas such as Southern Japan and the Caribbean. Studiesonseroconversion have clearly established that HTLV-Iistransfusion transmissible. To screen or not to screen for HTLV-I among the blood donor populationinThe Bahamasisthe question.Mycalculated projection is that thisisa matter of time. Purely because some blood banksinthe U.S.A. have started screening for HTLV-I among blood donors. Introduction of new testing programsandchronic shortages of blood supply have placed tremendous strain and impactonmodern blood banking practices. Iamof the opinion thatinThe Bahamas, there is a need for organisation of blood transfusion services. These measures would involve both technical and administrative ad justments for concrete improvementstooccur. They are as follows:(A)Administrative:1.Formation of a national blood donor organisation for the promotion of voluntary blood donationandtherecruitment of blood donors. The present blood procurement section shouldbeupgraded and given a national procurement responsibilities.2.Formation of fund-raising committeetosupplement effort of the Ministry of Health.3.Establishment of a national blood transfusion centre at hospital base centre. (B)Technical:1.Mechanisms for overcoming difficultiesinacquisition, storage, distribution and transportation of blood.2.Means of proper utilisation of blood and alternativestowhole blood.3.Ways and means of training health workersinbloodandblood product management.24-BAH.MED.J.-JAN.-JUNE,11990


soSm,rhKlmeBeechamIndications:Upperllowerrespiratorytractinfections: sinusitis.t.orlSillitis..otitis media. J.cute and chronic bronchitis. pneumonia.empyema.lung abscess. Skin andsohtissoe infections:boils!absces.ses..cellulitis.wound'infections.. intra-abdominal sepsis. Genito-urinary tr.lct infections: cystitis. urethritis. pyelooephritis.sepocabor1'on. pelvic infections. chdnc:rotd,gonorrhoea.Osteomyelitis., septicaemia. peritonitis. surgical prophylaxis.cIosall"':Adultsandchildren over I2ye.,...:One "'blettds.Children 7-I2years:IOmlofI56mgsyruptds.Children2-7years:Smlol I56mgsyrup tds. Children 9 months-2ye.,...:2.5ml011S6mgsyruptds.Children below 9 months: No suiublepresenutioncurrentlysevereinfectionsthedosagemaybedoubled.Intravenousdosage:Adultsandchildren over12ye.,...1.2g6-8hourly.Children 3 months-12 ye.,...30mglkg6-8hourly.Children below 3 months seepockinsert leaflet.SurgicalprOOhylaxis: Adults 1.2gatinductionof3Il3esthesia..ProceduresAUGMENTINisalongertIw1I hour require subsequent doses(upto4in24 hours). Tre>tment with AUGMENTIN should not be extendedbeyond1-4dayswithoutreview.Penicillin hypersensitivlty.Precautions:A number01nudies.thighdosageshaveshownAUGMENTINtobefreefromteratogenicityin animals:howeveritss;deryinhumanpregruncyhasnotyetbeenestablished.ThereisnoexperienceofAUGMENTINIV.inhumanpregnancy tilereloreitsuseinpregnancy cannotberecommended.ChangesinIrverfunctiontestshavebeenobservedinsomepatientsreceiVingintnvenousAUGMENTIN.Theclinical signifKafl(eofthesechangesisuncertainbut.AUGMENTIN shouldbeusedwith careinpatientswithevKicnceofseverehepatk: dysfunction. Dosage forpatientswithmoderateorsevererenal impairment shouldbeadjunedasdescribedinthepackinsertleafleLSide-effects: Uncommon,mainlymildandtnnSilOryegodiarrhoea.indigestion.nausea.vomiting. candidiasis.Ifgastro-intestinalsideeffectsoccu.-withoraltherapy theymaybereducedbyalting AUGMENTINatthestart01meals-Intheevent01iIIlurtic..-ia1orITlOri>4l1ilormr.oshdiscontinuetreatment-Phlebitis.tthesite01irjectionhasbeenreported_AswithsomeotheriIIltibacterialagents,a fewcases01hepatitisandchoIestaticjilUlldicehavebeenreported_Availabilitrl75mg AUGMENTINbbleu250mgamoxy

VIEWPOINTTHEDOCTORS'STORYAfter several years of formal university training to become a physician, one learnstoface unfair criticism. There is so much of work like preventing illnesses or saving lives that there just isn't the time to respond. Recently however,inthe local press, there have been a number of articles which have soughttoportray the physiciansinThe Bahamasasunscrupulous, uncaring money grabbers who are bentonmaintainjng their economic status(?!)even to the point of sabotaging a National Health Insurance Scheme. I believe thatitistimetoset the record straight. First of all let itbequite clear. The Medical Association of The Bahamas supports a National Health Insurance Scheme (NHIS) for The Bahamas.Itisquite natural foritto dosoafter all,itisthe Association which first put for ward theideain1979. The MAB has studiedingreat detail the NHIS proposals put forward by the Working Party. The MAB agrees with a major part of the proposals. However,ithas reservationsinseveral areas. Among the objections are the lack of provi sions for primary care and the inequitable imposition of the levy. The former would tilt the system towards tertiary care whichismore expensive and the latter would mean that 48% of the population wouldbeasked to pay the health care premiums for the entire population. It is important to pause here and reflect for a brief moment about whatittakes tobea physician. Very simplyitisas follows: consistently good high school academics, good grades at SATI'O' levels and 'A' levels followed by 4-8 years of sweat. There is no time to eat and often no time to sleep. After allwelearn about life, disease and death. Inter spersed in all this are a set of hostile examinations and worse hostile examiners. If one survives all this and it is esti mated that about 5-10% of students who enter premed eventually makeitthen oneisready to become an intern. This incidentally is only the beginning. Turbulent times lie ahead. And lestweforget...the cost thus farfor tuition alone can reach $200,000. It is not very often that physicians have the time or opportunity to open up and detail the dangers they face. There is the intense stress of the job.Itis not very easy to make critical decisions when fatigued. Thereisvery little time for the family. Thereisvery little opportunity to get a decent night's sleep. And crucial but very often forgotteninthe midst of everything else physicians areinthe front-line to pick up serious infections. Having said that then, let us discuss 'doctorsingeneral' andindoing so talk about the vast majority ofphysicians who provide health careinThe Bahamas. There are just about 275 physiciansinThe Bahamas. Of these 203 (73%) are employed by government. One must state here that thereisnevertheless a tremendous shortfallinthe physician manpower needed to provide the services needed.Nowonder then that 67% of the government employed physicians are expatriate. The Ministry of Health utilises strict scrutinising procedures prior to employing these physicians and the MAB supports it for that.Inthis number of 203 physicians employed by government there are31consultants who are allowed formal private practice and a few'acting' consultants who do private practice directly or by way of moonlighting. Each of the consul tants or acting consultants are fully certified specialistsintheir field and, but for a few, all are Bahamians. What this in dicates therefore is that the vast majority of physiciansinThe Bahamas i.e. 60% of all physicians and 80% of govern ment employed physicians are on fixed salary. The salary that these physicians earnislisted below.QUALIFICATIONS AND SALARY OF PHYSICIANSMinimumApproximate ApproximateQualifications+Numberofyears NumberofExperience after entering AnnualhoursworkedSalary Grade requiredUniversitySalary Per week Perhour1.Intern/House Officer MBBS or MD 5 $17.000' 70-80 $4.42.Senior House Officer MBBS or MD6-11$27,000 70-80 $6.9+1-3years3.Registrar MBBS or MD+/-Post 11-15 $29.500 70 $7.5 graduate Diploma+3 years4.SeniorRegistrar"MBBS or MD+/-13 $32.500 70-80 $8.3 Postgraduate Diploma+Postgraduate Degree+5 years5.Consultant" -asabove-15-20 $32.500'" 70-80 $8.3 Basicin-hospitalaccommodationandrationsareprovidedforinterns.Internshipisaperiodofadditionaltraining...Promotiontocategory4and5isnotautomaticandisdependentonfurtherqualificationswhichhavetobe obtained overseas ....Consultantsareallowedtheprivilegeofprivatepractice.26-BAH.MED.J.-JAN.-JUNE,1990


Itmust be stressedhere that the hours listed are conservative -Itisnot unusual for these physicians to be called upontoprovide critical solutions for critical problems oftenincriHcaisituations for 90-100 hours a week. And lest we for get that unlikeinTrinidad, Jamaica, Barbados, USA, Ireland andUIKthereisnosuch thing as overtime for physicians in The Bahamas.Noallowances are addedtosalary either. Thereisno motor vehicle allowance for on-call physicians.Itisimportanttonote that a physician whose spouseisnot employed does not fare very well at all and that is gross understatement. $8.3 per hour for specialist servicesisvery poor indeed. Let us turn nowtothe minority of physicians who areinprivate practice. As might be expected, some of these phy sicians are worked more than others and therefore earn more than others. The gross earnings of a fewinthis group may exceed $150,000. From this, however, the physician hastopay expenses e.g. full-time nurse, receptionist, office rent or mortgage and utilities. We all know that the vast majority of these physicians earn their wealth the old fashioned way working hard forit,often foranaverage of about 120 hours a week, for decades. We do believe that members of other professions who accumulate similar degree of wealth also work equally hard. A special note hastobe madeonbehalf of the Consultant physician staff based at the hospitals. This group of physicians provides the needed specialty and sub-speciality services to the public patient every day and every night-freeof charge.Inmany areas the consultant has justnochoice but to provide the service and is often called out al most every night and several times a night. Thereisjust no trained junior staff available. A few words also need tobesaid about the invaluable contribution madebythe expatriate physicians towards the health careinThe Bahamas. The Medical Association of The Bahamasiscognisant of this andisas keenly ,interestedinthe welfare of it's expatriate members as itisof it's Bahamian members. The good and solid work putinbythe majority of physicians is often wiped out and forgotten by the negative com ments directed towards a few of our colleagues. There have been complaints that the patient care, commitment and conduct of a few physicians has been deficient and that others have attempted to solicit a direct fee for service from the public patient. Whilewedo know that such complaints canbeunjust, the MAB believe. that repetitious complaints should be investigated and dealt with. The MABisjust notina position to defend the indefensible. The future can seeanincreaseincoststotrainasphysicians,tospecialise, and to maintain practices. There will be a strong need for the population at largetoreflect seriously and avoid behavioural patterns which will only serve to push the costofproviding health care skyrocketing. Change willbenecessary especiallyindrunken driving, promiscuity, teenage sexual activity, drug abuse, smoking, sexuall and other violence, overeating and non-compliance with physician advice. The salaries which are paidtothe physicians andtoother health service professionals will need serious review if we aretoattract and retain the services of quality personnel. The burden on the physician just has to be reduced or adequately compensated for. DR. ROBIN ROBERTSPresidentMedicalAssociationofThe Bahamas.April23,1990.(TheJournalwelcomesopposing/alternatecontributionstothiscolumnonthisoranyothermatterrelevanttophysicians,withtheunderstandingthatallsubmissionswillbesubjectedtoeditorialscissors.Ed.)BAH. MED.J.-JAN-JUNE,1990-27


Aviewtothefutureindiabetictherapy(NIDDM)Fastingbloodglucose(mmol/I)<0.001Adaptedf,omHaupt E.IOFBulletm,1987.31.mppl1,33pattern of Insulin secretion(2.31.Bycausing insulin to be secreted earlierInresponse to a glucose stimulus, Dlamlcron ensures that ItISsecretedJustat the right moment andInthe right amount.Inaddition, Itisnow well proven that Dlamlcron fights against Insulinresistance(4.5).D,amlcron helps restore the penpheral action of insulin. Diamlcron's particularly complete mode of action ensures maXimal efficacy and safetyInthe treatment ofallNIDDs.IoDiamicron ensures penn.nent blood glucose controlOlamicron's effective hypoglycaemlc ac tion(I)is reflectedinthe HbAI levels, a reliable indicator of glucose control throughout the 6-week penod which pre cedes the analysis. Dlamicron obtains these striking results becauseitresponds point by point to the fundamental underlying disordersofdiabetes mellitus. Aboveall,Diamicron restores a physiologicalI2monthsI3Diamicron fightsaiainstthe haemobiological disordersIndependentlyofitsmetabolicpropertles, Dlamlcron corrects the haemobiologicaldisordersunderlyingthevascularcomplicationsofdiabetes.Dlamlcron diminishes platelet hyper' activity: hyperaggregatlon(61and hy' peradhesiveness(71.Dlamlcron norma lizes vascular fibnnolysls(81.lnthis way Dlamlcron opposes the formattonofmlcrothrombl, the main causeofdla betic microangiopathy(9).(JJGU,II,JUHtiJUP)doll,LoJV,eWdIC.Jle.198].64479483(2)BrOi,lrdJMIn/erne1982.3J/9J87131HoskerJPel,ll,D!.JctlesRtsCionPrdCt.1985suo,,1I5250(4)GolJy AclJI,MedW!;cllr198411426/264(51Wdchjt'llberg)L('IOli.DIiJDeltsRes(1mPr,Jcf,/985.sup,,1J5592{6}fun""aer.1/rhromb Res.1979,16191203(7)OJ'o'tfJtldl,SemHooP,JrlS1913 49 279(8)A'mt'r[0,rhromtJRes/984, 35/925/9)Duh,IUI/)er;,1Opht.-,lmoJOitcd.17034552Gliclazlde2tabletsdaily((-1I"lLe.Laboratoire.Servler.Gldy45400FleurylesAubralsFranceCorrespondentInternational Servie'24,rueduPont.92200NeuillysurSeineFrance-

FAMILYPRACTICEUPDATE-AReport'n,-..!\;,-lllIlldCIIIII/erThefollowingareexcerptsfromthepersonalnotesJotteddownbyDr.CulmerduringtherecentFamilyPracticeUpdateattheMiamiIntercontinentalHotel.TheJournalwelcomessimilarreportsfromotherphysicianswhoattendupdates, conferencesandseminars. Ed.1.CURRENTTHINKINGINTHEMANAGEMENTOFURINARY TRACT INFECTIONS -BYDR.L.SAWHLowerUrinaryTract Infections in the lower urinary tract account for10to20percentofallUTI's.Theyaretakenverylightly, butifsepticemia occurs, fatalities can result. Septicemia most commonlyresultsfrom investigative and surgical procedures. When these proce duresaredone, it mustberemembered that the bladder becomes ladenwithinfected urine. Aminoglycosides and Cephalos porinsarethe antibioticsofchoicewhena urine cultureisnot available because theyarevery effective against both the gram positive and gram negative organisms. Anaerobesarenot a problem unless theGItractisviolated. TheBladderItisimportanttobefamiliarwiththe cause and mechanismofhoneymoon cystitis. During intercourse, bacteriaFromthe rectumareintroduced into the urethra, and thence to the bladder.Femalesmust pay strict attention to their bowel hygiene, and mustbecareful towipein the right direction.Sheshould empty her bladder immediately after sexual intercourse, and wash carefully immediately afterward. Studies have shown that the bacterial count increases after intercourse, andthus,itisrecommended that the bladder shouldbeemptied at least withinFiveminutes after intercourse. When thisisdone, the bacte rial count doesnotchange significantly.Theapproachtomanagement shouldbetotakepreventive measures, increase the fluid intake, and treatwiththe appropriate antibiotics. Treatment should continue for nolessthan7-10days.One dose treat mentsarenot very useful.RecurrentUTI'sItismost important toIlookForthe underlyingcause.A full workupismandatory includinganIVPand cystoscopy. Ana tomical and pathological entities mustbediligently soughtfor,bearing in mind, calculi, tumours, foreign bodies, sutures and anatomical anatoma,lies.UrethralSyndromeTheetiology and preventive measuresarethesameasdescribedforcystitis,but organismsareconfinedtothe glands in the urethra. Becauseofthis the cultures maybenegative. Microanalysis may show puscells.Thisisprimarily a ,femaledisease,and since antibioticlevelsin the urethraltissueareineFFectivelylowFollowing daytime therapy, itissuggested that the treat ment shouldbelong-term nocte...approximately30nights.ProstatitisThe etiology depends a great deal onitsanatomical relationships. Treatmentisdifficult becauseofthe fibrous composi tionofthe prostate anditsrelativelowvascularity. Infection maybeacquired by:-1.A multiplicityofpartners2.the reseNoir phenomenon whereby partnerspassbacteria back and forth.3.thecarelessuseofpublic toilets.4.Anal intercourse and5.In adequate treatment. The disease may be prevented by the practice of celibacy, theuseofcondoms, and the concommitant treatmentofpartners. The diagnosisismade by culturing the prostatic fluid. Urine cultureisinaccurate and contaminants are unaVOidable. The antibioticofchoiceisNorfloxacin, and therapy mustbeverylong-term. Other antibiotics to be consideredareTrimethoprim, Doxycycline, Minocyc/ine and Cephalexin.2.OBJECTIVESOFANTIHYPERTENSIVE TREATMENT -BYDR.C.FERRARIOThe primary goaloftreatmentisto reducetheincidenceoforgan damagedisease.The costoftreating cardiovascular diseasesin the US in a yearis588.2billion Significant advancesarebeing made resulting in the reductionofmorbidity and mortality. Factors affecting the incidenceofcardiovasculardiseasesareexcessiveweightgain, longer life span. dietary habits,stress,and'an increased salt intake.Theobjectivesofantihypertensive therapyisthe control and reductionofriskfactors suchasobesity, diabetes, smoking andstress.Thereasonsfor the treatmentofhypertrophy.Toprevent left ventricular hypertensionareprimarily to prevent vascular and renal damage, andtoreduce the incidenceofstrokes.Left venticular hypertrophyisan inde pendentriskfactor in sudden cardiac death.Themechanismofrenal injuryisprogressive glomerular d'amage leading to partiallossofrenalmassresulting in glomerulosclerosis and mesangial injury.Thevascular chanqes in hypertension works directlyonBAH. MED.J.-JAN-JUNE,1990-29


renal damage, and to reduce the incidenceofstrokes.Left venticular hypertrophyISan Independentriskfactorinsudden cardiacdeath.Themechanismofrenal injuryISprogressive glomerular damage leading to partiallossofrenalmassresultingInglomerulosclerosis and mesangialinJury.Thevascular changesinhypertension works directly on the brain due to the accelera tionofatherosclerotic disease.TheinCidenceofstrokeISincreasing. Common coexisting disordersarearthritis, angina, diabetes and asthma. The combinationofhypertension and diabetes mellitusisfound in40and 80%ofhypertensives. Usually type 2isthe accompanying disease.Manyofthese individualsshowevidenceofglucose intolerance, an Increaseinthe insulin level, obesity. elevatedsonlum,raised IntracellularcalCium.an IncreaseInsympathetic nervous activity, and altered sodiumc1CtlVltyTreatmentCommonsenseshould prevail. One shouldnotberestricted to the step guide.Forfirst line treatment. thereare50agents. thereare616twodrug combinations, and thereare3000 three drug combinations.RHODAE.HANNA#20KeltonHouse4thTerraceEast,CollinsAvenueP.O.BoxN-4850Nassau,BahamasTel.(809) 328-1940Office393-1363HomeBAHAMASMEDICALARTSINST,ITUTEDr.Patrick RobertsMDChild Health-Chest Diseases DEANS LANEATFORT CHARLOTIE NASSAU, BAHAMASP.O.BOX N1145 TELEPHONE (809) 328-80853D-BAH.MED.J.-JAN.-JUNE,1990Dr.David AllenMDPsychiatry-Stress Management


DIARRHOEA'Dr.Janel'Dallis-'Dorscttami'Dr.Julie'Wersfiill9Diarrhoeaisdefined as the presenceofmore frequent and/or more watery bowelmovementsthannormalforthatindividual. In ancienttimesitwas recognized thatthiswas the naturalmethodofeliminatingtoxicorinjuriousproductsfromthe body. Even in the earlier partofofthiscenturyitwasfelttobe advanta geous. In fact,theuseoflaxativesorpurgatives"tohasten along the emptyingoftheintestinalcanal"wasfelttobe"ofgreatservice".More recently, however, attention has been focused onthedangerofdeathfromsuddenorexcessivelossoffluidsand electrolytes. Most attacksofdiarrhoea are Short-lived, self-limiting andofunknownetiology. Yet, becauseofthesignificantfatality rate duetoacute diarrhoea in infants, rehydration andthepreventionoffurtherlossnowoccupythespotlight. Identifyingpossiblecausative agents has become animportantaspectoftheproblem.Incidence Diarrhoea is one ofthe major causesofchildhood morbidity and mortality throughout the world.Itis more signifi cantindeveloping countries, accounting for 12,600 deaths every day.Indeveloping areas or poorer districts,under 5 years age may have five or more episodes of diarrhoea per dayonat least 20-30 days of every year.ThiSISa significant contributing factorinthe incidence of malnutritioninthis populationTable 1 CHILDREN WITH DIARRHOEA HOSPITALIZED AT THE PRINCESS MARGARET HOSPITAL, NASSAU-1988Number admittedwithgastroenteritisbelow1 yearofage: Number admittedwithgastroenteritis 1-2 years age: Total Numberofadmissionsforgastroenteritis: Numberofdeaths in hospitalfromgastroenteritis:15130234oPathogenesis Diarrhoeaisanexcessive lossoffluid from theGItract, which may involve different mechanisms. This excessive loss maybedue to secretionoffluid and electrolytes from the crypt cellsofthe intestinal mucosa or to the failure of the cells of the villi to absorb fluid or electrolytes becauseofinjurytothecellsorbecauseofosmotic forcesinthe lumen. The excessive loss of fluid (accompanied by failuretoabsorb fluidsaswell), often with blood, mucous, and pusinthe stool, maybedue to injury to the,largeintestine.AetiologySecretory diarrhoeaisusually due toanenterotoxin fromaninfectious, metabolic or exogenous agent (suchasfoundinfood poisoning).Cytotoxicdiarrhoeaismost commonly causedbya viral agent, suchasthe rotavirus or Norwalk agent, but may alsobeduetoEnteropathogenicE.Coli, which causes destructionofthe cellsofthe small intestine.Osmoticdiarrhoea seeninmalabsorption syndromes, may also occur aftertheonset of secretory or cytotoxic diar rhoea. Thisisbecauseofthe interference with normal absorption (suchastemporary lactose intolerance) or because of the disturbance, by broad spectrum antibiotics of normal bacterial flora needed for digestion of food. Dysentr.ic diarrhoeaisduetothe inflammation and often ulceration of the mucosa and submucosa ofthe terminal ileumand large bowel andisusually duetoinvasive bacteria or protozoa. The specific causesofthe various typesofdiarrhoea are listedinTable2:Table 2 TYPES AND CAUSESOFDIARRHOEA Secretory:E.ColiV.Cholerae Clostridium difficile Clostridium perfringens Staph aureus Shigella Salmonella Yersinia enterocolitic Giardia Neuroblastoma Bacillus cereusV.parahemolyticus Cytotoxic: Rotavirus Norwalk agent CryptosporidiumE.coli Dysent9ric: Salmonella Campylobacter jejuni Entamoeba histolytica Yersinia enterocolitica Shigella Clostridium difficileE.ColiOsmotic:Lactose SorbitolBAH. MED.J.-JAN-JUNE,199(}-31


Several organisms (Salmonella, Shigella,E.Coli) may cause more than one type of diarrhoea, dependingontheir mode of action such as destruction of mucosa or releaseoftoxins.DiagnosisA careful history is probably the most useful diagnostic tool. Culture and organism identification by assay methods are important confirmatory measures, but results are frequently not available early enoughtohelpinthe initial selection of specific treatment. Historical points of particular value include: abruptness of onset, failure to thrive, recent food intake, source of drinking water, exposure to others with similar illness, recent travel, previous allergic manifestation, presence of system ic signs -fever, lethargy, weakness, vomiting, dehydration, abdominal pain, tenesmus, anorexia, distended or scaphoid abdomen, type of stool -consistency, volume, color, frequency, odour, content (blood, mucous, pus,fat,worms) and treatment already given.Table 3 SourceoftoxinorinfectionDrinkingWater/Seafood Campylobacter Salmonella ETEC,EIEC" ShigellaV.cholerae Giardia Yersinia Entamoeba Poultry Campylobacter SalmonellaC.perfringens MeatormilkCampylobacter SalmonellaC.perfringens EHEC Person-person Campylobacter SalmonellaC.diHicile EPEC,ETEC,EHEC Shigella Giardia Yersinia "ETEC=EnterotoxigenicE.Coli "EIEC=EnteroinvasiveE.Coli "EHEC=EnterohemorrhagicE.Coli "EPEC=EnteropathogenicE.ColiClinical assessmentDehydration, shock, electrolyte imbalance, systemic infection, malnutrition are all important features requiring as sessment. Since shock due to acute loss of circulating volumeisperhaps the most rapid cause of deathindiarrhoeal disease, it requires the most urgent recognition and treatment. Preventionofshock comes with early and accurate assessment of the state of hydration, and the replacementoflost fluid and electrolytes. The clinical signs of the various degrees of de hydration are listedinTable3.'Recent decreaseinweightisa valuable measure of acute fluid,loss.Table 4 Dehydration classification DegreeofdehydrationMild Moderate Severe32-BAH.MED.J.-JAN.-JUNE,1990%weightloss5% 10% 15%clinicalsignsIncreased thirst Decreased urinary outputDrymouth and lips Decreased tearing Sunken eyes and fontanelles Decreased skin turgor Pulse: Rate increased, volume decreased Fever, lethargy More marked oliguria Shock State Cool, pale skin Rapid thready pulse Diminished renal function


Table 4CompositionofOralElectrolytesolutionsGlucoseSodiumPotassiumGm/dlmeq/L meq/LCommercialsolutions:ORF (WHO solution) 2 90 20 Pedialyte 2.5 45 20 PedialyteRS2.57520Homeremedies: Galorade 5243Apple Juice120.4 26 Colas11.412 Ginger ale 9 3.50.17-up87.5 0.2 Dillseed lea 1.5-2194.3 Sweetened lea 1.5-2183.8 Fever grass lea 1.5-2212.1Dysenteric diarrhoeas may require treatment with antimicrobial therapy. Campylobacter jejuni relapses may be pre ventedbyErythromycin (if initiatedbythesecond day), but the course of the diseaseisotherwise unaffected. Treat ment of Salmonella (other thanS.typhi) may shorten the periodofsymptomatology but does not shorten the carrier state. Treatment of patients with Yersinia gastroenteritis (without sepsis)mayormay not be efficacious. The other dysenteric organisms shouldbetreated.Table 5AntimicrobialTreatmentfororganismscausingDysenteric Diarrhoea Campylobacter jejuni Clostridium difficile Salmonella Shigella Yersinia EntamoebahistolyticaNonSpecificTreatmentErythromycin 30-50 mg/kg/day Vancomycin 35-50 mg/kg/day Chloramphenicol 5-100 mg/kg/day Ampicillin 50-100 mg/kg/day T rimethoprim-sulfa 8-10 mg/kg/day Ampicillin 50-100 mg/kg/day Trimethoprim-sulfa 8-10 mg/kg/day Chlorampenicol 50-100 mg/kg/day Trimelhoprim-sulfa8-1Omg/kg/day Metronidazole 30-45 mg/kg/dayThe use of antidiarrhoeal drugsisusually110twarranted and,ingeneral,iscontraindicted. Agents, such as lopera mide diphenoxylate HCL, or bismuth subsalicylate have anti prostaglandin activity. If employed,theyshouldbeusedwithgreatcautionandNOTINCHIILDREN UNDER AGE 4 YEARS! Interference with the frequent stooling may cause the retention of toxins or organisms which the bodyisattemptingtogetridof and lead to a more severe disease state.Inaddition,bismuthsUbsalicylate can cause elevated serum salicylate levels which raises concern about Reye syn drome. Loperamide (Immodium, Imosec) can cause CNS depression and Diphenoxylate HCL (Lomotil) can cause se vere respiratory depression and coma. The problem with these drugsinyoung childrenisthe unpredictable absorption and availability. These agents may cause pooling of fluidinthe gut, thereby disguising the actual degree of loss of circulating fluid.Inaddition, the use of binding substances suchaskaolin or pectin may distort organismsinthe stool and impair micro scopic diagnosis.ConclusionDiarrhoeal diseaseisa leading 'killerininfantsandsmall children. Deaths can be prevented by prompt recognition BAH. MED.J.-JAN-JUNE,


Electrol,yte imbalance may resultinlethargy (with loss of potassium), convulsions (with excessive sodium), rapid shallow breathing (with excessive loss of bicarbonateandmetabolic acidosis) -allnecessitatingearly laboratory mea surement of electryolytes. Blood gas measurement,andespecially bloodpHisanaccurate method of assessing the degree of metabolic ac idosis. Fever, degree of activity or prostration, rash, cough, rhinorrhea, inflammed throatorears may suggest systemic in volvement rather than localizedGIdisease. Gross examination of the stool shouldbea part of the clinicalaswellasthe laboratory assessment. Examination of the stool by simple dipstick will reveal the presence of bloodanddecreasedpH.The latterisduetohydrogen ion production from carbohydrate digestioninthe large bowel whenitcannot take place normallyinthe small bowel. Visible blood and mucous,inthe absence of a perianal fissure, suggests a dysenteric type diarrhoea.LaboratoryAssessmentInitial blood tests should include electrolytes, blood urea, creatinine, complete blood count,andinthe case of fev er, blood culture.Indehydration without kidney disease, the ureashoUldbeelevated butthe creatinine normal. Hemoglobin deter mination may help assess the degree of blood lossindysentery, while elevatedWBCmay suggest a bacterial etiology. Fresh stools shouldbeexamined immediately after passage for occult blood, WBC, ovaandprotozoa,andprompt ly cultured. Special media may be required, dependingonsuspicion of the aetiologic agent(SSmedia, CampyBAP). WBCinthe stool may be accurately assessedbyadding a drop of methylene bluetoa thin smear of stoolona slide and adding the coverslip. 5 WBC/high power fieldissignificant. Gram stain may reveal excessive short rods(E.Coli) or the "gull-wing" gram negative Campylobacter. Urinalysis may reveal unusual loss of glucose, poor concentration, the presence of acetone (with significant vomit ing) or the presence ofWBC(confirmedbya positive culture) suggesting a urinary tract infechonasthe primary cause of the diarrhoea. Specific rapid tests have been developed recently for such organismsasRotavirusandCampylobacter. Other diagnostic tests suchasthe hydrogen breath test for lactose intolerance maybeusefulindifferentiating true lactose intolerance from bacterial overgrowthandsmall bowel pathology. Treatment The chief aim of treatmentinacute diarrhoeaistherestorationofthe normal stateofhydration and normal electro lytebalance. The prevention of further loss of fluidandelectrolytes maybepossiblebytreating the specific causative agent, once itisidentified. Secretory andcytotoxicdiarrhoeas are treated withfluidreplacement and maintenance only. The early use ofanoral rehydrating solutionhasproved extremely advantageousinpreventing severe dehydration and even death. Several commercial types are now available locally (Table4).Mildtomoderate dehydration canbesafely treated without the use ofIVfluids. Theuseof rehydrating fluid (Na60-90meq/L)inthe first4hours of treatment shouldbesufficienttoreplace the lossandsupply maintenance fluid. After that, the useofa maintenance solution (Na40-50meq/L) maybeusedtosupply the maintenance fluids plus any additional loss from diarrhoea. Alternately, a rehydrating solution maybeusedtocorrect the dehydrationandsupplytheinitial maintenance for the first four hours. Then water or breast milk maybegiven, with the rehydration fluid used only when a loose stoolispassed. The introduction of food after the first16hoursisnot only harmless but promotes more rapid recovery. Severe (greaterthan10%)dehydrationshouldbepromptlyadmittedtothe hospital and treated withIVflu ids.34-BAH.MED.J.-JAN.-JUNE,1990


of dehydrationandthe institution of oral rehydration therapy. Dehydration, itself, may actuallybepreventedbytheearly replacement of fluids before the loss becomes critical. If necessary, hospitalizationandthe administrationoforal fluidsbymedical personnel, or parenteral fluids are effectiveinthe prevention of death. These preventive measures dependoneducationofparentsandnursery personnelinthe dangers of fluid lossinchildren.Evenmore important are the preventive measures of good sanitation, careful handwashing, and sterilization of infant feedsandutensils.CONTROLOFDIARRHOEALDISEASE-MEDIACAMPAIGN'Dr.'DI/flid'8mll,'Dr lj.'/)eckles,.Mrs.1;)1'1/(','}{o!dcr,,:\'(1'5./al/'!fi;l/ler-'Roadi, ,Mrs.'J'.)olil/sol/IIml.Mr.'D.'Rllllld('l'IIDiarrhoeal diseaseisone of the leading causesofmorbidityandmortality among children the world over. Oral Rehydration Therapy (ORT) has been a key factorinreducing the number of deaths which result from dehydration. Every householdinTrinidad and Tobago has a radio and/or te'levision. The aim of this project was to develop and evaluate a Radio and TV oriented health education program to change the knowledge, attitudes and practices of Trinidadian mothers with children under age 5 years,rediarrhoea, dehydrationandoral rehydration therapy. A radio and television campaign to educate the people of TrinidadandTobago regarding Diarrhoea, Dehydration and Oral Rehydration Therapy (ORT) was donein1985. Two advertisements addressed the prevention of gastroenteritis and two, the treatment of gastroenteritis. Sanitation, nutrition and ORT were emphasised. Breast feeding wasanessen tial component of both advertisements. The same words were used for each radio and TV advertisements.InMarch 1985, five hundred mothers who had just given birth were questioned by two trained interviewers at the three major hospitalsinTrinidad and Tobago. Three hundred and sixty of the mothers were located and requestioned by the same interviewersinNovember, 1985. This campaign resultedina significant improvementinthe public's, i.e. mothers of children under the age of 5 years, knowledge, attitude and practicesrediarrhoea, dehydrationandORT. We therefore highly recommend continued adver tisementsonradio andTV,not onlyinthe area of gastroenteritis, butinother crucial paediatric situations e.g. prenatal care, nutrition, child developmentandinthe treatment of common local diseases like bronchial asthma and febrile convu Isions.AdditionalcorrespondencetoDr. David Bratt, DepartmentofPaediatrics, PortofSpain General Hospital,PortofSpain,TrinidadandTobago,W.1.BAH. MED.J.-JAN-JUNE,1990-35




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