The GPHC hierarchy needs to address the simple things that can save lives

Aug 11, 2018 Letters

---

Dear Editor,

Thirty-four years ago, my mother died at GPHC because of doctors’ negligence. I was nine years old but made a promise that I’ll become a doctor and be the voice for voiceless patients.
I have read in the printed media that Guyana has a resident cardiologist. I will not comment on his training since that is not the purpose of my missive. I wish to explore the workings of the Caribbean Heart Institute (CHI). I will use the British Cardiology Society, American College of Cardiology, American Heart Association, Society of Cardiovascular Angiography and Intervention guidelines as gold standards.
Editor, one of the medical procedures performed at the CHI is percutaneous coronary intervention (PCI). A PCI is quite invasive and has serious risk. One of the most serious complications is coronary artery dissection. This occurs in two of 100 procedures but can be higher in centres that perform PCI infrequently. Without surgical treatment, the patient will have an inevitable painful death. As a result, it is recommended that centres undertaking PCI should ideally have a cardiothoracic surgery unit on site or one in close proximity. Guyana does not have a cardiothoracic surgery unit or surgeon. Therefore, when at least two out of 100 patients have their coronary artery dissected they will simply be left to die. For me that is playing Russian roulette with patients’ lives.
Also with PCI, there is a risk of cardiac arrest from arrhythmias. As a result, it is imperative that the cardiologist and his support staff have up to date training in advance life support (ALS). I doubt whether the cardiologist or his support staff have ALS training since ALS training is not available in Guyana.
Ideally, any PCI centre should have at least two cath labs in the event that one develops problems while doing a procedure, it can be completed in the second. Also, a PCI centre should have a least three cardiologists. As far as I am aware, the Caribbean Heart Institute just has one resident cardiologist. In addition, as far as I am aware CHI has one cath lab. Is this safe? Again, I will say that the CHI is playing Russian roulette with patients’ lives.
It is recommended that PCI centres do a minimum of 400 PCI per year and PCI operators do at least 75 PCI per year. Because of limitations of space, I cannot provide the supporting research evidence that underpins these recommendations. PCI in Guyana is quite costly (US$1000-6000). Most Guyanese cannot afford it. I doubt whether more than 30 PCI are done per year at CHI. Whoever is undertaking the PCI is at risk of becoming deskilled increasing the likelihood of complications, which can result in patients’ death.
I recently read in the printed media that GPHC has had a paired renal transplant. I know a renal transplant is not just taking a kidney from a donor and transplanting it to a recipient. It not only requires HLA and blood group matching of donor and recipient. It also requires counselling of both donor and recipient by trained psychologists. It requires screening the donor for cancers and infectious diseases. It requires screening the donor for any conditions that can predispose to renal failure in the future. In requires doing ruins test for the donor. Were these done?
After a transplant, the patient will require at least a week in hospital with strong immuno suppression. Levels of the immuno suppression in the blood will need to be monitored. After discharged, the patient will have to be reviewed weekly for the first two months. Again, levels of immunosuppression in the blood will have to be monitored weekly. I am confident that Guyana does not have laboratory facilities to monitor immunosuppression levels. As a result, it will have to be taken overseas. The problem is that too little immunosuppression will result in rejection while too much will harm the transplanted kidney. So it is important that the level is right and the result is available in a timely manner. With the test going overseas, it is likely the results will not be timely putting the patient at serious risk of losing the transplant.
Also there will be occasions when the transplant may develop problems. This may require special ultrasound to assess its blood vessels and its structure. That’s not available in Guyana. In addition, special types of blood tests may be needed; e.g. CMV and parvovirus PCR. Unlikely that is available in Guyana. The patient may require a kidney biopsy. Who will do it? If done, who will examine it? Guyana does not have a histopathologist.
Then I saw a Paediatric Intensive Care was opened by the Minister of Health. The fact is that this fancy building and sophisticated machines are useless without the required staff. Guyana has no Paediatric Intensivist; critical for a paediatric intensive care. No Paediatric Intensive nurse. No chest physiotherapist. None of the present paediatric doctors can do umbilical catheterisation, arterial lines, central lines, endotracheal intubation, Paediatric advance life support among other skills.
Rather than investing in that building and sophisticated machine, just use that money for serious basic shortages present in the hospital. Also, invest in the health centres since they have serious shortages. The paediatrics’ doctors who are unskilled are just playing Russian roulette with innocent children lives. Attempting procedures that they are not trained to do.

I would humbly suggest that the hospital hierarchy recognises the limitations of GPHC and focus on the simple things that can save lives. Send a few doctors to Canada to be trained as family doctors. They can play a key role in preventive medicine. Diabetes and hypertension are major clinical problems in Guyana. Employ at least three endocrinologist and diabetologists to address this. Strict management of blood sugars can save limbs and lives.
Finally, now that this information is in the public domain, I trust that the medical director will take steps to address them. Regards

Dr Mark Devonish MBBS MSc MRCP(UK)
Consultant Acute Medicine

---

---