Guyana wrap-up part 3.

When I landed in Guyana, I crossed the threshold into a completely novel environment, spiked temperatures, intense greenery and an overwhelming sense of a placid way of life. My first exploration of the country was an extraordinary trip to the heart of the rainforests to see the famous Kaieteur falls.  The Orninduik falls were fascinating, separating the country of Brazil from Guyana.

I was also introduced to “chutney music“. Has anyone heard about it? Believe it or not, it is a mixture of rural Indian ‘Bhojpuri‘ music that has amalgamated with the local and English tunes and has become very popular in the Caribbean. I also visited a Hindu temple. It was a strange feeling at first. Even though the scriptures were being read in an accented tone of Hindi, no one understood and the priest explained in English. This was a first for me, I mean Hindu temple with the puja (read service)  in English! However, after a few minutes, the language of the puja became irrelevant and I could have been in India.

The streets of Georgetown are lined with red flaming gul-mohar trees, coconut, jackfruit and mango trees loaded with fruits, as well as blooming lotus and water lilies. Nature appeared at its best here.

I also came to know about the only musical instrument that was invented in the 20th century. The steel-pan! I could not fathom how the Beethoven’s sonatas could come out of this simple steel drum but they did!

 

Beth and I had an extraordinary time together. I don’t think residents ever spend 1 whole month with a consultant or vice versa. We came to know about each other’s lives, families, wishes, likes and more importantly, dislikes! I now know that Beth is an excellent teacher and has a lot of patience. Together, we experienced a 7.3 Richter earthquake, watched a Bollywood style dance drama, ate dhal poori and craved for cucumbers! She now knows that I am terrible with board games, love to cook and hate doing dishes. I now know that she loves animals and will pet stray dogs, cats and even donkeys, regardless of their cleanliness and ticks/fleas status!

 

Thanks to all of you who followed me during this 5 weeks journey! This will be my last blog regarding Guyana. Let us see what happens in 2019.

Bye for now.

 

Guyana wrap-up part 2.

What I learnt in Guyana was the ability to have a sensible judgement without judging. Safety is an issue in Guyana, this is a known fact. However, that did not mean that we did not go out or socialize. Like anywhere else in the world, there were good people and there were bad people. To be able to survive in a place considered risky/corrupt is a valuable skill that I needed to bring back with me, after 5 weeks in Guyana.

This was a poster on one of the streets of Georgetown.

The other thing I learnt was to stop seeing Guyanese healthcare with a Canadian eye. These healthcare providers work with extremely limited resources so who am I to judge? In similar circumstances, would contemporary healthcare providers be able to provide the same level of care?

I carried an ultrasound machine that Sonosite had loaned me for the purpose, specifically. I wonder if I should have collected donations to buy the machine from them for the purpose of teaching. Guyanese anesthesia and ICU residents would have benefited so much. Though the whole ensemble fitted in a backpack, it did give me a bit of trouble during the check-in process at the airports (it was 14 kg and had 2 lithium batteries) but overall, it was an excellent idea and worked well. I am attaching a picture for you, Lina Lee!

For most of our days in Guyana, we stayed at a wonderful place, Project Dawn, a brainchild of Sister Carmen who was a nun and later became a doctor to help Guyanese people. After her passing, the place is being maintained by Marcie Gravensande. The place was wonderful, safe, spacious, with 24 h security and air-conditioning, had an excellent kitchen and lounging space. Each person was given a loaf of bread, a jar of peanut butter, a bag of ground coffee and a litre of milk that was good to give us a headstart. Each group marked their own food supplies and we did as well! Marcie told me that though many doctors come, only a few come back.

 

 

Guyana wrap-up-part 1.

My 5 weeks volunteering trip with CASIEF has come to an end. I will be wrapping up the trip in 3 parts. I have met many new people, made many new friends and seen a different way of life. I came here with a notion of poverty and suffering. It just goes to show how wrong one can be when one makes an opinion without actually experiencing it.

I found out that the perinatal and under-5 mortality is high, much higher than most countries of the world (shocking numbers: perinatal: 2.8%, under-5: 3.6%). Obstetric analgesia is a rare occurrence, the C-section rate is high. SAO providers (surgeons, anesthesiologists, obstetricians) are stuck in the 20th century with minimal CME possibilities/desire/both. None of the patients speak Spanish but the majority of doctors have been educated in the Spanish language in Latin America and therefore communication with patients is not their forte! Postoperative pain management is limited to IV morphine for all patients in the recovery room. The patients appear very sensitive to opioids and do not seem to need much. However, the Wong-Baker pain scales posted at each bay in the PACU by my predecessor are just posters on the wall, still there. Over and over again, I heard patients tell me “pain is life“.

External partnership programs for post-graduate anesthesia training are being implemented so hopefully there will be changes. Perhaps the success of the CASIEF endeavour will be defined by not the number of people who go to Guyana but the strength of the partnership programs and the effect it will have on the residents. Residents are very keen. I would say they are hungry for knowledge and try and do their best with the limited opportunities for learning. I felt sad when I was teaching ‘massive transfusion’ to a group of residents who have very limited access to blood and none to blood products.

I think I learnt more than I taught! I learnt how to provide anesthesia when supplies are irregular; sometimes drugs and equipment were available and at other times, not. Choosing between absolute sterility and reusing the sparingly available supplies was a hard task, probably the hardest during this journey. Here in Canada, we take disposable single-use equipment and drug availability for granted. When local anesthesia shortage happened in North America (a few months ago), I remember how disturbed everyone was. This is a common occurrence in Guyana! During my stay, the supply for bupivacaine came and it was called ‘Numbicaine‘. The pediatric tylenol is called ‘babygesic‘. How appropriate!

 

The best part of the trip was teaching regional anesthesia to a bunch of very enthusiastic residents who couldn’t wait to practice their skills (sometimes on a patient and at other times on a pumpkin). The nadir of the trip, however, was not in Guyana but when I returned. With new eyes, I saw the absolute waste of drugs and equipment in Canada whereas ORs in Guyana (and I am sure in many parts of the world) are cancelled due to lack of equipment, drugs, sterile gowns; absolutely anything!

 

Heart-breaking stories & St. George’s

There have been other heartbreaking stories, just like Ned’s. The Hansen’s disease patient died the next day. I remember how Beth injected lidocaine in his ear so that perfusion would improve and she was able to record the SPO2, successfully. I remember his vehement refusal for Foley’s and then quietly saying that he takes a size 18F catheter.

Nancy came to the pain clinic for pain management. She had no investigations with her. She had a fracture of the arm that no one had looked at. When a colleague asked her for new investigations, she was very hesitant as it was not affordable and she had to ask her nephew who supported her and lived in the US.

Chronic pain management is unheard of. Acute pain management is not far off. Obstetric patients cry in pain for the lack of analgesia. No families or loved ones are allowed to be with them. Many of them have heard of pain-relief but do not expect it.

On my last day in Georgetown, I visited the St. George’s Anglican Cathedral which was built between 1889-1894 and is the tallest wooden structure in the world. It has an old world charm with a tropical flavour. Large windows at the lower level can be opened to let in the Atlantic breeze! The beautiful stained glass windows higher up depict the life of Christ. The pipe organ is massive. The chandelier in the church is a gift from Queen Victoria. Unfortunately, I could not get a close enough picture as there were preparations for the next day service going on. Like most of Guyana, it needs some TLC!

Stained glass windows of the chruch

Queen Victoria gifted this chandelier

The cathedral

The massive pipe organ

Guyanese history

This is a country that was ruled by the French, British and Dutch. To my amazement, there is nothing reminiscent of those times except the names of towns. The only influences that I could see are Indian and African even though neither India nor Africa ever ruled this place.

Both these genetic pools moved to this country between18- 19th century, some as slaves and others as indentured servants and brought their culture, food and religion with them and to this day, this is how they live. The roads are lined by churches, Hindu temples and mosques. People’s names do not depict any religion here. I have met Samantha who is a Hindu, Ravindra who is a Muslim and Indira who is a Christian. So simple and without any religious bias. No one’s religion can be identified by name. Guyanese people have made their lives simpler. How wonderful!

Unfortunately, during this long journey from Africa and India, the language was lost. The English here is spoken in a  sing-song way that reminded me of my childhood when West Indian cricketers visited India and the Doordarshan (Indian TV channel and the only one those days) broadcasted Clive Lloyd’s interview. This is how he spoke! I remember Clive Lloyd so well. Only today I came to know that he is Guyanese and lives in Georgetown! I think I may have seen him during the cricket match we had gone to see that day. The cameraman had focussed on someone who did not belong to the Guyana warriors but was sitting in the pavilion and now that I think of it, he was the BIG C!

Last week in Georgetown

This is my 5th and last week here in Guyana. I am having mixed feelings as I have got used to the 7.30 pick up by the hospital driver Noel, on the way to the OR, buy lunch of roti and either chicken or pumpkin curry (Beth’s favourite and mine too) and then go and change into scrubs. I am usually lugging the Sonosite on my shoulders so the first stop is the Anesthesia room to park the machine and put it for charging. Morning 8 am is usually still early so there is enough time to peek in all ORs and check the list. The list almost always changes so there is no point in checking it the afternoon prior.

OR matron Sister Gill asked when I will come back and I was surprised when I heard myself saying ‘next year’! The nurse in charge of the OR is called matron and when I had asked her name, she very clearly had articulated ‘SISTER GILL’ with emphasis on the ‘sister’.

Today I cleaned the anesthesia cupboards that had supplies brought in by various visiting teams over the years and the sterility date was long past (10-12 years past!). Dr Martin, nurse Debra and I sorted out the stuff so that the supplies can be accessed. This was such an accomplishment. Even though I am not OCD, today I felt like one.

Tuesdays are the days that I looked forward to. It is the pain clinic afternoon and patients are so thankful for us seeing them and hearing their story. They are usually non-complaining, God-fearing and just there to know if we could help them. Most of them have chronic health issues, hypertension, diabetes, coronary artery disease. None of them is on any opioids. So different from the typical chronic pain patient of North America! Today I felt sad when the physiotherapist brought Ned (not his real name) who was shot in the spine in 2009 and has used a walker since then. His pain was more of diabetic neuropathy type but he wanted to know if I could help him walk though he has not walked since 2009. He had heard that I have done epidural steroids and wondered if that could help him walk. I am not sure who was more disappointed, he or I? He just said, ‘don’t worry Doc. This is life’.

Not all was sad this Tuesday. Epidural steroid patients from the past weeks came for a followup visit. Daisy (not her real name) has been coming every Tuesday since her epidural steroid just to tell me that it was ‘night and day’. This Tuesday she came to say goodbye as she knew I was leaving. Don (again not real name) came as a followup. He had an inadvertent dural puncture during the epidural teaching process. He was walking better and smiling. He said he could do their physiotherapy much better and promised me to that he will take his blood pressure pills and statins. Thank God, no PDPH! AnnDee has had a good response to gabapentin and acetaminophen and that is wonderful news as there is nothing else available.

I will miss the Tuesdays clinics.

 

Essequibo river trip

Our weekends here in Guyana have been pretty amazing and I want to share this one with you too.

On Sunday, I took a trip up the Essequibo river that is the largest river in Guyana. It is more than 1000 Km long but does not even make to the list of top 10 of South America! The estuary (the uninformed me had to look up what it meant) is 20 km wide. Can you imagine? All rivers in Guyana (read South America) are either muddy due to silt or black/brown due to the plant tannins. They do not originate from glaciers so the waters are not clear.

I boarded a small bus, crossed the Demerara river and after a short halt in the town of Parika, reached a place called Roed-en-rust. With 30 other people, I boarded a ‘jet boat’ which was a larger version of a speedboat. 15 min of boat ride at 30 km/hr, we reached the Fort island, the house to ruins of Fort Zealandia, the oldest structure in Guyana and a UNESCO heritage site. It was named after Zeeland, a Dutch province. The history of the place is so interesting, the rulers changed from Dutch to French to British with the baton moving back and forth a few times! There is a Court of Policy building where apparently slaves were traded and our guide told us that they were probably beheaded too! Such a shameful part of the past. The island does not have electricity or fresh water, houses about 30 families and believe it or not, there is a medical centre and a school too. I would have loved to get into the medical centre but unfortunately, it was closed.

There are many islands (364 to be exact) in the river Essequibo, some of them larger than the country of Barbados. One entire island is owned by Eddy Grant, the founding member of the British pop group ‘Equals’. It is rumoured that it was sold a few years ago but no one can be sure.

The country’s maximum security male prison is where the Mazaruni river joins the Essequibo. Though it is on the mainland, one needs to access it via the Essequibo river so even local Guyanese are surprised when they learn that it is not on an island. I was told that jail-time may not be a deterrent but rather an attractive option to desperately poor people as they get free meals, paid work and a roof over their heads.

 

The flora and fauna of the area are wonderful. The country has a raw beauty that the tourism industry has not messed up, at least not yet. There is a variety of fish including monster fish Piraiba, the newly discovered air-breathing fish Arapaima and crocodiles in the river so I heaved a sigh of relief when my feet touched the ground and the bus had returned to Georgetown. Back to work, last week in Guyana.

Mangroves of Essequibo

Our jet-boat

Fort Zeelandia

Fort Island

Court of Policy Building

Demerara and the Eldorado rum

Did you know that Demerara sugar comes from the sugarcanes in Guyana?

I have always enjoyed the golden yellow/brown crystals of the sugar in my coffee but did not know that it came from the molasses of the sugarcanes that are grown in the Demerara region of Guyana! We are staying in the Demerara-Mahaica region here in Guyana and the big bridge that connects Georgetown to rest of the country is also called Demerara so the sugar in my coffee back home becomes more important. Does it not? The remarkable Eldorado rum also comes from Guyana and is considered one of the best rums in the world and since 1992, it has repeatedly won awards in its category. It is called the true gold of Guyana. I can personally vouch for its smoothness and velvety taste. Though I am a wine drinker, I think Eldorado has the power to convert me!

Shawn, an Guyanese doctor who was an ENT fellow in London, Ontario took us over the Demerara bridge one night. It is the 4th longest pontoon bridge in the world and is 1.8 km long. Pontoon bridge is a floating bridge and barges/boats/pontoons support the bridge deck. Pretty neat, isn’t it? The deck moved a lot when we drove over it and then when we were on the walkway, it shook a lot when cars/trucks went by. A passing car slowed down to enquire if we were planning to jump in the (crocodile and snake infested) river! The river is also called Demerara, is nearly 350 km long, has powerful current and drains in the Atlantic ocean. The bridge opens at scheduled times to allow ships (5000 tons) to go through! There is a network of large rivers all over Guyana that are the drainage basins for this very fertile land. No wonder the fruits taste so good here.

 

End of work week 4

It is unbelievable that 4 weeks have gone by, so quickly. Beth will be leaving this Sunday and I am staying for another week.

Work week was very good, we had so many things to do, learn and teach. The showpiece of the entire teaching month was the first journal club that we organized this Thursday. The 4 final year residents presented 2 papers that we had selected for them, early in August. The residents were excited albeit a bit apprehensive and I must say, appeared scared, initially. They had never spoken to an audience or presented an article. Beth is a great teacher and together, we helped them refine their presentations and finally, they pulled it off, and wonderfully so. Well done Maxine, Tiffany, Shellon and Smolana, we are proud of you! There was good discussion and all residents participated, asking relevant questions. They also arranged for a little pizza party during the half time break between the presentations. Well planned and executed! I hope the oncoming visiting team keeps up this journal club activity.

Cases during this week were very interesting as well. We had a 92 year old patient with Hansen’s disease for fracture femur. Beth had never seen a case of Hansen’s disease so that was a learning experience for her. There was another very elderly woman who supposedly had a hip fracture but Xray could not be done due to pain. A femoral block (planned and guided by me, supervised by Beth and done by the Guyanese resident) allowed the C-arm to be used and it turned out that there was no fracture! I have been going around with the US machine demonstrating its uses wherever needed; a-lines, peripheral lines in kids, blocks in adults/kids, teaching spinal scanning. It has been a useful thing to bring, I must say.

We have been going to the pain clinic every Tuesday. We have done 2 epidural steroids. One patient returned, very happy. The second one will return next Tuesday, hopefully with good results.

Today was the last day for Beth with the residents. They gathered together and organized a little farewell speech and a going away present for both of us. Such a lovely and thoughtful gesture!

I bought a pumpkin for teaching epidural needle and catheter insertion as there is no other way residents could experience the ‘loss of resistance’ feeling especially as there are not many occasions to do an epidural. This turned out to be an excellent idea and residents practiced their LOR to air as well as saline and catheter threading skills in the pumpkin. Necessity is indeed, the mother of invention. I plan to bake the pumpkin next week, before returning home!

!

 

Mid-week post: great invention!

Great inventions have always been made in emergency situations, so I have been told. Though it will never turn out into a great invention, kudos to the presence of mind of the caregiver who came up with this quick and indeed very clever way of modifying a broken wheelchair to make it functional!