Postoperative analgesia in the Jamaican cannabis user.

BACKGROUND: Anecdotal reports suggest that cannabis users require increased postoperative analgesia but there is insufficient supporting data. METHODS: A prospective randomized study was carried out in 73 patients undergoing elective operations. Postoperatively, all patients were assessed by a blinded investigator, who recorded pain intensity, sedation levels, mood, and hourly analgesia requirements. We calculated the mean pain intensity difference at the first postoperative hour (MPID1) and the sum of pain intensity differences (SPID1). The following end points were compared between cannabis users and non-users using SPSS 16: MPIDI; SPID; patient mood; supplemental analgesia requirements and global assessment scores. RESULTS: There were 42 cannabis users and 31 non-users. Cannabis users had significantly higher supplemental pethidine requirements (82.7 mg, SD = 3.4 vs. 51.6 mg, SD = 42.7, p = 0.003) and significantly greater MPID1 scores (1.88, SD = 1.09 vs. 1.35, SD = 1.12, p = 0.001) compared to non-users. Female cannabis users required significantly more analgesia than males (93.3 mg, SD = 45.8 vs. 78.3 mg, SD = 44.3, p = 0.025). CONCLUSION: Cannabis users require significantly more opioid rescue analgesia in the immediate postoperative period. Further research is needed to elucidate the precise mechanism by which this occurs.

Emergency department physician training in Jamaica: a national public hospital survey.

BACKGROUND: Emergency Department (ED) medical officers are often the first medical responders to emergencies in Jamaica because pre-hospital emergency response services are not universally available. Over the past decade, several new ED training opportunities have been introduced locally. Their precise impact on the health care system in Jamaica has not yet been evaluated. We sought to determine the level of training, qualifications and experience of medical officers employed in public hospital EDs across the nation. METHODS: A database of all medical officers employed in public hospital EDs was created from records maintained by the Ministry of Health in Jamaica. A specially designed questionnaire was administered to all medical officers in this database. Data was analyzed using SPSS Version 10.0. RESULTS: There were 160 ED medical officers across Jamaica, of which 47.5% were males and the mean age was 32.3 years (SD +/- 7.1; Range 23-57). These physicians were employed in the EDs for a mean of 2.2 years (SD +/- 2.5; Range 0-15; Median 2.5) and were recent graduates of medical schools (Mean 5.1; SD +/- 5.9; Median 3 years).Only 5.5% of the medical officers had specialist qualifications (grade III/IV), 12.8% were grade II medical officers and 80.5% were grade I house officers or interns. The majority of medical officers had no additional training qualifications: 20.9% were exposed to post-graduate training, 27.9% had current ACLS certification and 10.3% had current ATLS certification. CONCLUSION: The majority of medical officers in public hospital EDs across Jamaica are relatively inexperienced and inadequately trained. Consultant supervision is not available in most public hospital EDs. With the injury epidemic that exists in Jamaica, it is logical that increased training opportunities and resources are required to meet the needs of the population.

Epidemiology of tetanus in Jamaica, 1993-2010.

BACKGROUND: Although tetanus is still endemic in Jamaica, the epidemiologic profile has not been evaluated. METHODS: Admission registers at the main tertiary referral hospital were accessed to identify all patients diagnosed with tetanus from 1 January 1993 to 1 December 2010. RESULTS: There were 26 cases of tetanus (annual incidence of 0.57 cases per 1,000,000 population). Tetanus was more common in men (5.2:1) at a mean age of 59 ± 18.1 years. Persons in high-risk occupations (farmers, gardeners and construction workers) accounted for 52% of cases. CONCLUSIONS: Tetanus remains endemic in Jamaica, occurring more commonly in elderly men. Doctors should be educated about the importance of a high index of suspicion, an immunisation history and promoting booster shots in high-risk groups.

Overcoming obstacles to establish a multidisciplinary team approach to hepatobiliary diseases: a working model in a Caribbean setting.

INTRODUCTION: By providing a structured forum to exchange information and ideas, multidisciplinary team meetings improve working relationships, expedite investigations, promote evidence-based treatment, and ultimately improve clinical outcomes. METHODS: This discursive paper reports the introduction of a multidisciplinary team approach to manage hepatobiliary diseases in Jamaica, focusing on the challenges encountered and the methods used to overcome these obstacles. CONCLUSION: Despite multiple challenges in resource-limited environments, a multidisciplinary team approach can be incorporated into clinical practice in developing nations. Policy makers should make it a priority to support clinical, operational, and governance aspects of the multidisciplinary teams.

Leadership in surgery for public sector hospitals in Jamaica: strategies for the operating room.

The barriers to health care delivery in developing nations are many: underfunding, limited support services, scarce resources, suboptimal health care worker attitudes, and deficient health care policies are some of the challenges. The literature contains little information about health care leadership in developing nations. This discursive paper examines the impact of leadership on the delivery of operating room (OR) services in public sector hospitals in Jamaica.Delivery of OR services in Jamaica is hindered by many unique cultural, financial, political, and environmental barriers. We identify six leadership goals adapted to this environment to achieve change. Effective leadership must adapt to the environment. Delivery of OR services in Jamaica may be improved by addressing leadership training, workplace safety, interpersonal communication, and work environment and by revising existing policies. Additionally, there should be regular practice audits and quality control surveys.

Revisiting current strategies for primary prevention of motorcycle collisions in Jamaica.

Motorcycle Road Traffic Collisions place a heavy burden on emergency medical services in Jamaica. We explore the existing strategies and legislative policies that may prevent or reduce the severity of these injuries in Jamaica. This is an important aspect of health care as it may minimize the impact of these preventable injuries on the limited resources of the health services.

Cost-benefit comparison of hemodialysis access creation in a developing country and North American centres.

OBJECTIVE: It has been suggested that vascular access operations should only be performed in high-volume centres to ensure good outcomes. Vascular access operations have been routinely performed in the Cayman Islands since 2005. However, with an estimated population of 45,000 persons, only a small number of patients require vascular access in any given interval. A cost-benefit analysis of this practice was performed. METHODS: All patients who had vascular access operations over four years were retrospectively identified. Two groups were defined - the local group, who had operations performed by surgeons in the Cayman Islands, and the offshore group, who were transferred off the island and had operations overseas. Cumulative cost, morbidity, patency and failure rates were compared. Significance was considered present with a two-tailed P≤0.05. RESULTS: There were 14 patients in the local group and 22 in the offshore group. The mean cost of access creation was 6.9 times greater in the offshore group (US$26,883.36 versus US$3,913.33; P<0.001). The likelihood of the use of arteriovenous grafts was significantly greater in the offshore group (P=0.04). When therapeutic outcomes were compared, there were no differences in primary or secondary failure, primary or secondary patency, or overall access-specific morbidity. CONCLUSIONS: In the present setting, vascular access creation exceeded all the goals set by the National Kidney Foundation Kidney Disease Outcomes Quality Initiative and the Fistula First Breakthrough Initiative. Compared with overseas centres, this is being achieved at a significantly lower cost, with a greater likelihood of native fistula use and similar therapeutic outcomes.

The impact of helmets on motorcycle head trauma at a tertiary hospital in Jamaica.

BACKGROUND: Although the Jamaica road traffic act mandates motorcycle riders to wear approved helmets, opponents suggest that the local road conditions obviate any benefits from helmet use that have been proven in Developed countries. They suggest that the narrow, winding, poorly surfaced, congested local highways do not allow motorcyclists to sustain high velocity travel. The accidents then tend to occur at lower speeds and are accompanied by less severe injuries. This study was carried out to determine the impact of helmet use on traumatic brain injuries from motorcycle collisions in patients admitted to a tertiary referral hospital in Jamaica. METHODS: A prospectively collected trauma registry maintained by the Department of Surgery at the University Hospital of the West Indies in Jamaica was accessed to identify all motorcycle collision victims from January 2000 to January 2007. The therapeutic outcomes of traumatic brain injuries were compared between helmeted and un-helmeted riders. The data was analyzed using SPSS Version 12. RESULTS: Of 293 motorcycle collision victims, 143 sustained brain injuries. There were 9 females (6.3%) with an average age of 23 +/- 7.3 years and 134 males (93.7%) at an average age of 33.4 +/- 11.2 years (mean +/- SD). Only 49 (34.3%) patients wore a helmet at the time of a collision. Helmet use at the time of a collision significantly reduced the severity of head injuries (28.6% vs 46.8%, P = 0.028) and the likelihood of sustaining intra-cranial lesions (26.5% vs 44.7%, P = 0.03) from head injuries. CONCLUSION: Wearing a helmet at the time of a motorcycle collision reduces the severity of head injuries. However, the prevalence of helmet use at the time of a collision is unacceptably low.

Inter-hospital transfer of trauma patients in a developing country: a prospective descriptive study.

UNLABELLED: There is no standardised protocol for the transfer of injured patients in Jamaica, a process that is well known to be potentially hazardous. We undertook this study to evaluate the inter-hospital transfer process of injured patients in this developing country. MATERIALS AND METHODS: A prospective descriptive analytical study of all consecutive patients transferred to the University Hospital of the West Indies from other hospitals was conducted over six months. Data were collected on specially designed proformas and analysed using SPSS version 10.0. RESULTS: Of 122 patients studied, 79.5% were male and the mean age was 27.8+/-20.7 years. Most injuries resulted from road traffic accidents (40.2%), falls (27.1%) and assaults (26.2%). Several problems with the transfer process were identified. There was poor documentation of clinical parameters at referring institutions, with records of pulse rates in 13.1% (16/122), blood pressure in 9.8% (12/122), respiratory rate in 9.8% (12/122), Glasgow Coma Score in 10.6% (13/122) and pupillary reaction in 4.9% (6/122) of cases. Transfer arrangements were made by junior medical officers in 93.4% (114/122) of cases while consultants requested only 3.3% (4/122) of transfers. Public hospital ambulances transported 91.8% (112/122) of patients and 7.4% (9/122) were transported by helicopter. These vehicles were equipped with facilities for oxygen administration in 99.2% (121/122) of cases and sphygmomanometers in 91% (111/122) of cases, but functional capacity for suction was only present in 50% of vehicles. These critically ill patients were accompanied by physicians in only 11.5% (14/122) of cases, while 68.9% (84/122) were accompanied only by nurses. CONCLUSIONS: The transfer of injured patients is not being performed in a manner consistent with modern medical practice. There is urgent need for implementation of a standardised protocol for the transfer of such patients in Jamaica.