One of the most enduring themes working as a doctor in Mabaruma has been: access. This place is 24 hours by 'steamer' from Georgetown, 8 hours by speedboat + bus, or for the lucky few, an hour by plane. The steamer is an experience I will never forget, more about that on another blog, but not for the faint of heart (or any other illness for that matter). The speedboat has, we are told, been troubled by overinterested pirates, and the plane only goes on alternate days, and is quite expensive - definitely beyond the reach of most Region 1 residents.
So with Georgetown Public Hospital being the only referral centre in the country, Mabaruma Hospital needs to be equipped and manned to cope with sick patients who need stabilising before being transferred. But it isn't, and the transfer facility creates a great big hole in the Regional Health budget, so it is avoided where possible. There is also a cultural factor that anyone who has worked in A+E will recognise. I saw it first when the RHO (Regional Health Officer), who takes ultimate responsibility for all transfers, puffed out her chest and said 'We can manage this ectopic pregnancy - they deal with much worse stuff in Port Kaituma'. She wants us to be seen as the ballsiest and most capable region.
This makes for some very hairy situations. For anyone who doesn't know about ectopics, they are pregnancies that implant where they shouldn't, and as they fix into their tissue of choice, usually a fallopian tube, they try to develop a blood supply to the foetus. At about 8 weeks into the pregnancy the blood vessels rupture and the mother can end up with a devastating internal bleed, requiring blood transfusion and an operation. These are two things we are without in Mabaruma (no blood, no surgeons). The careful clinician will pick up early signs of an ectopic and urgently refer to a gynaecology ward, and breathe a sigh of relief as he does so. I saw my first ectopic a couple of weeks into my work here, and I was not granted that relief: 'Let's observe and see what happens' the RHO stoutly advised and my hair thinned a little further.
Sometimes it isn't quite that urgent, but patients still need the expert care they can only get in Georgetown. For example we get a lot of snake bites here, especially just after its rained. The important species is called labaria. It's a small snake with a helical stripe running down it's brown/ green body. The venom can cause bleeding - from the puncture site, but also elsewhere, particularly the gums, which are inspected daily. Any sign of bleeding warrants a tranfer in the next 24 hours as it usually escalates and requires a transfusion.
More trivially, broken bones need the Xray facilities not available here, and eye injuries need examining properly using kit we just don't have. These all have to go to the capital eventually.
One taactic I have developed is to 'collect' patients to please the RHO's purse strings. Here's how it goes: in addition to the commercial flight there is a charitable aeroplane, a rather cute Cessna 4 seater in yellow, run by two families, one pilot from each family. Their purpose is to help with medical evacuations and they have undoubtedly saved many lives in so doing. However, fuel is a big cost - about 100 quid per trip - so the Ministry of Health pay for that. This means the RHO still has budgetary issues to consider with this service. How to make her use it? Get as many patients as possible into the plane: 3 in the seats and one in the baggage area at the back (it needs to be a small child that doesn't weigh too much) and sell the idea to RHO. It tends to go something like this: 'I've got a snake bite, a broken arm, a high risk pregnancy and a girl whose eye was hit by a green mango - can we use the yellow plane?'
Without the yellow plane the budgetary pressures would be such that many serious cases would not get the care they need. Either that, or the poor patients would be put through 24 hours of vomiting hell on the steamer. It is a fine enterprise, and everybody who reads this should help them! Here is the link for their website: US:: http://www.wfhguyana.org/, or Canada: http://www.flywfh.org/ all donations go directly to the costs of upkeep of the plane.
So with Georgetown Public Hospital being the only referral centre in the country, Mabaruma Hospital needs to be equipped and manned to cope with sick patients who need stabilising before being transferred. But it isn't, and the transfer facility creates a great big hole in the Regional Health budget, so it is avoided where possible. There is also a cultural factor that anyone who has worked in A+E will recognise. I saw it first when the RHO (Regional Health Officer), who takes ultimate responsibility for all transfers, puffed out her chest and said 'We can manage this ectopic pregnancy - they deal with much worse stuff in Port Kaituma'. She wants us to be seen as the ballsiest and most capable region.
This makes for some very hairy situations. For anyone who doesn't know about ectopics, they are pregnancies that implant where they shouldn't, and as they fix into their tissue of choice, usually a fallopian tube, they try to develop a blood supply to the foetus. At about 8 weeks into the pregnancy the blood vessels rupture and the mother can end up with a devastating internal bleed, requiring blood transfusion and an operation. These are two things we are without in Mabaruma (no blood, no surgeons). The careful clinician will pick up early signs of an ectopic and urgently refer to a gynaecology ward, and breathe a sigh of relief as he does so. I saw my first ectopic a couple of weeks into my work here, and I was not granted that relief: 'Let's observe and see what happens' the RHO stoutly advised and my hair thinned a little further.
Sometimes it isn't quite that urgent, but patients still need the expert care they can only get in Georgetown. For example we get a lot of snake bites here, especially just after its rained. The important species is called labaria. It's a small snake with a helical stripe running down it's brown/ green body. The venom can cause bleeding - from the puncture site, but also elsewhere, particularly the gums, which are inspected daily. Any sign of bleeding warrants a tranfer in the next 24 hours as it usually escalates and requires a transfusion.
More trivially, broken bones need the Xray facilities not available here, and eye injuries need examining properly using kit we just don't have. These all have to go to the capital eventually.
One taactic I have developed is to 'collect' patients to please the RHO's purse strings. Here's how it goes: in addition to the commercial flight there is a charitable aeroplane, a rather cute Cessna 4 seater in yellow, run by two families, one pilot from each family. Their purpose is to help with medical evacuations and they have undoubtedly saved many lives in so doing. However, fuel is a big cost - about 100 quid per trip - so the Ministry of Health pay for that. This means the RHO still has budgetary issues to consider with this service. How to make her use it? Get as many patients as possible into the plane: 3 in the seats and one in the baggage area at the back (it needs to be a small child that doesn't weigh too much) and sell the idea to RHO. It tends to go something like this: 'I've got a snake bite, a broken arm, a high risk pregnancy and a girl whose eye was hit by a green mango - can we use the yellow plane?'
Without the yellow plane the budgetary pressures would be such that many serious cases would not get the care they need. Either that, or the poor patients would be put through 24 hours of vomiting hell on the steamer. It is a fine enterprise, and everybody who reads this should help them! Here is the link for their website: US:: http://www.wfhguyana.org/, or Canada: http://www.flywfh.org/ all donations go directly to the costs of upkeep of the plane.
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1 comment:
Great blog Sam - you're really getting down to the hard stuff, aren't you? We will give a donation to the plane fund but it won't be a very big one. Any ideas how we can try for funds in the UK? Your description of the needs of the sick people would prompt people to give. Sometimes bad situations feel so enormous they make you feel helpless but the smaller scale i.e. your hospital might make make people feel they can make a difference in a tangible way. Well done Dr.Sam, luv Monica
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