A Specialist’s view on the operation of the GPHC’s A&E Unit

Nov 29, 2015 News

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—stresses need for substantial funding
The Accident and Emergency (A&E) Unit at any hospital is very important. Here, in Guyana, the Georgetown Public Hospital (GPHC)’s A&E is dubbed “the gateway to Guyana’s public healthcare system.”

Its operation has been gaining close attention from world renowned Professor of Emergency Medicine, Dr. Kenneth Iserson. Dr Iserson is one of the first Emergency Medicine Specialists in the United States. In fact the author of the famous medical book ‘Improvised Medicine’ has helped to develop the specialty in the US, and has also been doing so globally.
Dr. Iserson, who is well respected among emergency physicians, recently shared his thoughts about visiting Guyana and sought to highlight what measures can be taken to help improve the GPHC’s A&E Unit and by extension, the delivery of health care.
Below are the responses to some questions recently posed to Dr. Iserson.
WHY DID YOU COME TO GUYANA?
It was supposed to be a one-time trip so I could help at a relatively new Emergency Medicine training programme. I work and teach around the globe, particularly in resource-poor countries. Having worked in rural sub-Saharan Africa, I am familiar with resource scarcity—Guyana is not at that level. My experiences working in Antarctica showed me what medicine in an isolated setting is like—Guyana’s interior has some of those qualities. Yet, Guyana is uniquely different from any of these locales: relatively poor and with an underfunded healthcare system trying to serve the needs of an urban, rural and remote population.
WHAT WAS YOUR FIRST IMPRESSION OF THE GPHC’s A&E UNIT?
When I first entered Guyana’s GPHC Accident and Emergency (A&E), it fit my expectations for a poor country’s typical neglected public hospital: overcrowded, understaffed, and poorly equipped.
The waiting room was jammed with patients and families, many in wheelchairs or on stretchers. Staff and visitors were passing through the department for easy access to the hospital. Very ill patients filled the broken stretchers, and other extremely ill patients filled the mass of chairs inside and the benches outside the department.
Occasionally ambulance stretchers held patients between A&E beds. The few staffers sweated profusely (the AC usually didn’t work) as they worked to keep up with the patient flow, sometimes having to take over “bagging” a patient in whom a breathing tube had been inserted, since no intensive care beds or ventilators were available in the hospital.
The referral phone was almost constantly ringing with calls from a regional hospital, or an interior health clinic signaling that physicians were transferring a patient needing more help than they could provide. Unfortunately, many calls also came from private hospitals that would no longer care for a patient who had run out of money. That was what was obvious.
WHAT WAS IMPORTANT ABOUT GPHC A&E THAT YOU DID NOT IMMEDIATELY SEE?
What I did not initially appreciate was the extraordinary talent and motivation of the Guyanese physicians training in Emergency Medicine and the dogged commitment of their Vanderbilt University Emergency Medicine faculty. (Reference is being made here to Dr Zulfikar Bux who currently holds the position of Head of the A&E Unit)
The first class of Guyanese Emergency Medicine residents consisted of one physician. On my first visit, he was in his last year of the three-year programme. A University of Guyana graduate, he shared a vision for the future of the specialty and for improved emergency medical care throughout Guyana. Two larger groups of residents were in their first and second years.
Based on the U.S. model for training Emergency Medicine specialist physicians, the GPHC programme represents the optimal graduate medical education model that other less-developed nations can follow.
Of the eight residents who have graduated, seven work at GPHC and one has returned to direct emergency care in her homeland of Antigua and Barbuda. All are now providing the highest levels of emergency care that is possible given the limited resources they have on hand.
HOW LIMITED ARE THE PUBLIC MEDICAL SYSTEM’S RESOURCES?
Most people outside of the medical profession do not realize that Guyana’s public healthcare system has no Labaria (poisonous snake) antivenin, no clot-busting drugs for strokes, no rabies vaccine, no free CT scanning, very limited x-ray capability, and inadequate medications, medical supplies and equipment. These shortages are even more acute in the regional hospitals.
Of course, CTs, x-rays, and many medications are available in the private sector. This often frustrates our GPHC emergency physicians, since they would love to diagnose and treat their patients using the optimal methods, medications and equipment. That, unfortunately, is often not possible. Guyana’s public health system is truly resource-poor — although this is often due to bureaucracy and unfortunate management rather than a lack of finances.
WHY DID YOU REPEATEDLY RETURN TO GPHC AND GUYANA?
That is a good question. I retired about six years ago from the University of Arizona as Professor Emeritus of Emergency Medicine. Since that time, I have worked only in Global and Disaster Medicine. My pattern has been to work in a country, or a health care site (often at Emergency Medicine residency programmes), only one time. I try to contribute some sustainable changes to the local health system by not only treating patients, but also teaching health care professionals.
What I found in Guyana changed my pattern. The quality of the Emergency Medicine residents, faculty, nurses and staff offers me an opportunity to help shape what is undoubtedly one of the Caribbean’s premier training programmes for physicians.
Instead of just traveling the world (I still do that also), I now have worked as part of the GPHC educational family for about three months a year for several years. Over this time, I have seen wonderful changes in how GPHC delivers Emergency Medical care, with a promise of great things to come. These changes will not only lead to improving Emergency Medicine care in Guyana and the Caribbean basin, but also will produce domestic and international physician leaders. For me, this is what sustainable educational assistance is about.
For example, our first graduate, Dr. Zulfikar Bux, became the A&E Department Head and the first Guyanese consultant in EM. He has improved A&E’s functioning—including providing patients with a measure of privacy, and also has begun educational outreach to government agencies and regional hospitals, helped develop a robust EMS (ambulance service for the public) programme, and supported the vital professional specialization of Emergency Nurses.
CAN WE IMPROVE THE SYSTEM?
While Emergency Medicine in Guyana holds great promise, a lack of vision means that many sick patients still must sit in chairs rather than recline on A&E stretchers. Often, too few monitors (or working monitors) are available for critical patients, vital laboratory tests (such as to diagnose heart attacks) are unavailable, and patients may wait many hours for x-rays.
Improving this situation depends on a real administrative commitment to upgrade the facilities, and to supply adequate equipment, personnel, space and beds. Managers and bureaucrats must find ways to solve the problems rather than obstruct the solutions.
Most importantly, rather than ignoring the GPHC A&E, they must devote substantial and constant funds and attention to its improvement so that its high-quality physicians and nurses can do the job for which they have been trained.
Guyana has an opportunity to deliver some of the best emergency patient care in the region with its human resources and international support services. The bureaucracy has prevented this for the most part, but I am now more encouraged by the leadership that is beginning to take shape. They now have the opportunity to transform the face of the medical system by supporting the vital development of emergency medicine and emergency departments in the country.

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