The following article was submitted to the Sunday Gleaner by a medical intern.
My experiences as an intern working at the Kingston Public Hospital (KPH), Victoria Jubilee Hospital, Bustamante Hospital, National Chest, and health centres in the Kingston area in 2004 have left me shocked and dismayed at the attitude, response, management, planning and implementa-tion of health care strategies for the majority of the citizens of this country.
My middle-class upbringing in Jamaica, or should I say my false sense of reality, didn't prepare me for the shock of KPH.
On entering the wards, the congestion and overcrowding were the first things apparent. Second was the stress and anxiety on the faces of doctors and nurses. The shortage of basic equipment was alarming. At one point, red-topped tubes to collect blood for electrolyte analysis and cross matching were out of stock. From syringes, to branulas, to antibiotics and pain medication, KPH runs short on a chronic basis. I routinely stole from other better equipped hospitals to maintain my 'private stash', which I dipped into frequently to augment the meagre supplies at my disposal. You can't imagine how frustrating it is to hunt for a single item like a branula, so you can site an IV on a shocked patient.
out-of-pocket expense
If this lack of basic equipment is a daily reality, then why do we even think it remotely possible for a major trauma centre like KPH to be blessed with a CT scan machine? In the public sector, a subsidised CT brain done at a private radiology centre or at UHWI, costs $10,000. With 60 per cent of the patients who come to KPH being unemployed, and only 15 per cent of our population having access to health insurance, does the Government really think that this cost is affordable as an immediate out-of-pocket expense to the vast majority of our citizens? Surely this service must be subsidised and not tied directly into the over-burdened diagnostic units within the hospitals themselves. Hospital diagnostic units are overwhelmed by sheer volume and backlog. It takes two months if not more to get an ultrasound as an outpatient at KPH or other hospital which offers the service.
Overwhelmed technicians in cramped quarters have to play "troubleshoot that machine" each night to get ageing, improperly maintained machines to work magic. For the entire Kingston area, a small emergency lab at KPH handles all the blood investigations for all the public hospitals after 4:00 p.m. Surely one would think that Bustamante Hospital would have its own emergency lab, able quickly to provide results for medicine is a field where haste is essential for emergency cases. Up to very recently, KPH did not have a functioning arterial blood gas machine, an essential tool in managing patients across the specialities. We had to send them to Bustamante, to overtax its own small unit. (So an URGENT arterial blood gas (ABG) request means "after 2-3 hours, if lucky"). The National Chest Hospital does not have its own electro-lyte or ABG machine. Note to the Government: A one-week-old electro-
lyte panel is meaningless in patient management.
Speaking of diagnostic equipment, a simple ECG machine was not available on the medical wards at KPH after 4:00 p.m. The one functioning machine is located in the emergency room, and this must be wheeled all over the place, to Jubilee, to the medical wards, to the surgical wards if an urgent ECG is needed. One Friday evening, the machine in accident and emergency was broken. So the 'rule out myocardial infarction' patient went without an ECG for the weekend. And the urgent blood studies took three days to come back, as only basic blood studies are available on weekends. Can you imagine how embarrassing it is, at the largest hospital in the English-speaking Caribbean, to give relatives prescriptions for heart attack detection kits, and even pain medication, to tell them, go to the pharmacy and purchase these things, so I can treat your family member who is IN hospital?
no portable ultrasound machine
Victoria Jubilee Hospital only has one old CTG machine to monitor moms' contractions and babies' heartbeat for the entire hospital! There is not even a portable ultrasound machine on the maternity ward. The one large fixed unit on the ground floor is impractical to deal with obstetric emergencies on the third floor. I mean really, does it take a rocket scientist to figure that out?
Surely an effort should be made to streamline elective surgical cases, so that it doesn't take four months for an elderly gentleman to get his hernia repaired. While on general surgery, we never got to complete an elective list, because of the trauma patients who would come in and bump our patients off the list. All the effort of admission, the cost of investigations, the time off from work, are wasted as an hour before surgery, a hernia patient was cancelled because some young punk "decided" to get himself "chopped up". The simple solution would be to have two operating theatres on stream to deal with trauma, and have a general surgery team assigned to handle trauma cases in a particular month, while allowing the other teams to proceed with elective cases uninterrupted. If it takes six admissions to hospital before you can get an operation done because of repeated cancellations then imagine the mental stress, decreased productivity, and waste of resources.
We cannot even ensure that blood results for Jubilee Hospital are sent to Jubilee and not mixed in with hundreds of other KPH patients a simple task in this computer age. You should see the chaos as interns vie for access to various sheets of paper to find results, and dig into old piles to unearth results from days or weeks before. Why can't blood results go to their respective wards?
I have also heard of cases where the "wrong" patient was transferred and the UWI ambulance was hurriedly sent back to retrieve the patient in question. Imagine receiving a hastily written referral letter from UHWI with no investigations and a comatose patient at 2:00 a.m. on a KPH medicine ward that has a capacity for 40 patients but currently has 70 because you as the sole intern have admitted 30 patients over the last 12 hours? What do you do when, as you finish sorting out the patient, a nurse says that five more are coming up from the "UHWI night bus"?
Primary health care has also been mismanaged. Health centres that should deal with the majority of patients who pile into casualty rooms with non-casualty complaints are not functioning because of understaffing. And they are understaffed because salaries are low. Casualty departments at Type A, B and C hospitals across the islands are bursting at the seams with huge patient volumes. Often in rural areas, doctors are at health centres only once or twice per week. With the cost of seeing a private GP out of reach, where do the patients go? And how do they get medication when hospital and health centre pharmacies, which represent the only source of subsidised drugs, are open once a week because of lack of pharmacist staff? Why is it that rural hospitals have to be scurrying back and forth to find ambulances? Why aren't their X-Ray departments properly staffed? Why are capable facilities underutilised, while others are overwhelmed because they have to take on extra volume?
working to exhaustion
Government needs to wise up to one fact: Degrees in the medical sciences require the average Jamaican student to place himself or herself in tremendous debt during the education phase. With student loan payments for my colleagues averaging $40,000 per month, how can you offer a graduate doctor a basic salary of $62,000 per month to be a first year intern in your hospitals, working 100 hours a week? At Jubilee Hospital last year, interns were working from Saturday morning at 8:00 a.m. to Monday afternoon at 4:00 p.m., covering four wards, admissions, existing patients and emergencies. These young Jamaicans work to exhaustion in your system for a paltry sum. Are you surprised when they leave this country and enrich others with their talent and dedication?
The colossal failure of the health care system over the last several years to provide for poor people in our country is a well-kept secret. It's a secret because those out of the system don't understand the need and desperation, the look on a mother's face when she comes to a clinic with pus pouring out of her newborn's eyes because she couldn't afford to come to even the public health facility earlier. I think it's high time people from all walks of life were made aware of these realities, and to help put pressure on the authorities to put the necessary resources in the system.
As for me, I am proud of my country; I love my people, but I'm leaving. Sorry.
I am, etc.,
A Young Jamaican Doctor
Sad to leave, but going.
