Nadine Harris

One of the best things about healthcare delivery in Guyana is that it is nationalized.  Care is free and available to every citizen.  It is financed and managed through the Ministry of Health working together with regional and local government. There is an independent private sector.   However, despite a national health system, there are several gaps in the delivery of health care in Guyana.

Chronic diseases, such are hypertension, diabetes and heart disease, are becoming more prevalent in Guyana and currently there is not an infrastructure in place to help manage this growing problem.  Patients are presenting to the emergency department at advanced stages at which time there may not be great treatment options available.    Unfortunately the regional health center, which would ideally be the place for primary care, is not very equipped. There is usually just one physician available to staff a large local population and he/she may not be well trained to manage chronic disease.  The availability of equipment such as blood pressure cuffs, glucometers, monofilaments, debridement tools for diabetic ulcers are often in limited supply. Lab testing and monitoring are usually not available.  The idea of routine screening and preventative medicine is nonexistent.  Ancillary staff, if available, is also not well trained. 

While most patients living along the coast have access to some sort of health care, whether through regional health centers or the local emergency department, those who live in the interior have little to no access.  This is largely because of the sparse population and difficult terrain. The population comprises mostly of indigenous people and miners - in emergency situations, they travel for days to the capital to receive care.

In Guyana, there is very little support for persons with mental health disorders or substance abuse.  During my short time in Guyana, there were more than a handful of persons presenting with suicide attempt, often with paraquat, a freely available but deadly herbicide.  At a public health level, there needs to be better regulation of who has access to these poisons as this is an easily preventable cause of morbidity and mortality.   There is poor education about mental illness among the population as well as among providers.  If a patient survives a suicide attempt, he/she is discharged from the hospital without any resources or treatment to address with underlying mental illness.  Substance abuse, specifically alcohol, is never addressed.  Training providers as well as the development of a psychiatric unit or treatment center will be a small step to help address this growing problem. 

One of the largest challenges to health care delivery in Guyana is the lack of an integrated health information system.  Medical records are completely on paper and patients’ charts do not go with them throughout their contact with the medical field.  The medical record is not used to support decision making.  For example, if a patient presents to the ED with hypertensive emergency, a new chart is made up for the admission.  Even though the same patient presented a week prior with the same issue, the record is not automatically included and there is no way to use information about their previous treatment to guide treatment decisions now.  In addition, the contents that make up the medical record are sometimes sporadic and often incomplete.

There are many areas that need to be built up for the health care system in Guyana to become what it needs to be.  There needs to be programs in place for advance training of physicians and compensation and work plans that keep these well trained physicians interested in staying in Guyana. Local health centers need to become the first line for screening and management of chronic diseases.  Also, within the public health sector education programs need to be developed that teaches local population about disease, mental illness and a healthy lifestyle.

In Guyana, there appears to be a commitment by the government to improve the overall healthcare delivery system.  With the monetary support and partnership with many foreign agencies, Guyana is slowly on its way to delivering the care its people need.

Nadine Harris

All I can say is, I don’t know how they do it. I have finished my time in A&E and have been on female medical ward for the last week and a half. The female medical ward is housed in a new facility that opened several months ago. There are approximately 8 patients per room.  Patients have to bring their own sheets, clothes, toilet paper, water, and any other supplies that they might need.   There are many nurses and even more nursing students around, but I have yet to figure out exactly what they do.  Care by the nursing staff is haphazard at best.

It is so busy here!  There are two interns who take care of 60-80 patients at any given time and every 3^rd day they do a 36 hour shift.  Rounds every morning are quite exhausting and interminable.  We either help the interns pre-round (this may involve checking vitals, starting IVs, updating orders) or we round with the sole internal medicine consultant (in the country!) during bedside teaching rounds.   There are about 20 medical students who attend these rounds and it is the only semi-structured teaching they receive during their internal medicine rotation. I spent some time going over a few cases with them and though they are eager and enthusiastic to learn medicine I worry about how they will develop the skill sets needed to identify and manage disease processes.

Unfortunately, because the wards are so busy and it is often only the interns around to manage patients, many things are missed or overlooked.  Labs take a long time to return and once they do show up may be forgotten until the next day on rounds.  A patient’s clinical status may deteriorate without anyone recognizing or alerting a physician of the change for hours.   There is a lot of death and, unfortunately, sometimes it seems all but inevitable. 

Despite all the obstacles present, the best part about being here is the patients I get to work with.  There is such a sense of gratitude and appreciation for the care that they receive and readily acceptance and trust even when things do not go quite right.  There is such strength and resilience in the human spirit.

Yesterday was the last day of the rotation and I spent part of the day in medical records going over a couple charts of patients that I had heard about or taken care of.   As I sat on the hard wooden bench, in the cloying sticky heat waiting for them to pull the records, I looked around and saw the tall shelves of recorded births and deaths at GPHC for the last 50 years.  It was particularly striking to me at that moment that somewhere amidst all of that paper, the record of my birth could be found.  Looking at GPHC currently, it is hard to imagine what it must have been like so many years ago.  Nonetheless, I feel like I have come full circle and I never could have predicted it.  I am grateful for the opportunity to be here and I look forward to creating opportunities to come back to teach, work and help build up the healthcare of Guyana.

Nadine Harris

It is good to be back in Guyana.  It has been a week since my arrival and there is a feeling of returning home.  Although I left this country when I was very young, the culture, the food, the sayings, even the hot humid climate and cooling ocean breeze are all so familiar and welcomed.

I have been working in A&E at Georgetown Public Hospital, the country’s tertiary care center, for the last 5 days.  I am amazed at the broad spectrum of pathology that we see in any given day - some of these have included cerebral malaria, snake bites, herbicide poisoning, tetanus, advanced HIV, acute myocardial infarction, infected diabetic foot ulcers, and strokes.  What is most impressive to me is how many complications I have seen from poorly controlled chronic medical conditions, many of the same disease processes that we deal with in the US.  As an internal medicine resident, I think about my own panel of patients back home and how aggressively we are taught

to manage diseases such as hypertension, diabetes, and coronary disease.  Unfortunately, this is not possible in Guyana in large part due to lack of a trained physicians to take care of these people and poor medical records (surprisingly, many of the first line drugs that we use to manage chronic illness are available here).  Guyana, like so many developing countries, continues to struggle with “brain drain” as more and more trained professionals migrate in search of a more economically secure way of life.  In the medical profession, those who are left behind do the best they can, but are often overworked and undertrained. 

Working in a developing country with so limited resources certainly requires that I adjust the way I think about and approach a disease process; this is easier said than done.  The emergency medicine residents do the best that they 

can to be aggressive in the resuscitation of very sick patients - unfortunately, often with so few ICU beds, ventilators, equipment for monitoring, it is difficult to sustain a high level of care for the critically ill and many do not survive.

There is just so much that we take for granted in the U.S.  I met a 17 year old girl who was brought in to A&E by her parents with 6 months of a progressive motor weakness and spasms that left her wheelchair bound and in sign

ificant pain.  She had been in and out of the hospital, with essentially negative work up including lumbar puncture, plain films and CT head.  She had seen a private neurologist and needed a MRI.  Due to the cost she has not yet gotten the test and even with her consultant advocating her case to the ministry of health, the outcome is still pending.  Getting such a simple test that is so easily accessible to us in the U.S. seems an almost insurmountable hurdle to overcome in the work up of her disease.

It is humbling experience to be here and is a great reminder of what a privilege it is to be able to practice medicine and to serve those who need the most help.  I am constantly being reminded to how much I don’t know and how much I can learn from my patients.

Kelsey Tipton

During the time that has passed since my last report I have been focusing my attention on the Tennessee Radon project. As I mentioned before I really have become interested in this particular project. Through my contacts I have been able to acquire short term radon tests to distribute throughout the community. Thus far I have received scores on 15 of the 20 test kits I have sent out. A safe radon rating for your home under is 4 pCi/L, so far ever test I have gotten back has scored under “1” pCi/L which is great! It has been rewarding to be able to go into the community and pass out the short term radon test not only because I can get data to record, but also because I can talk with the participants and help them to understand the major affects radon can have on their health. I feel like I am truly making a difference in some of these peoples’ lives and helping them understand what could be happening in their home is an eye opening experience for most.

Now that we are more than halfway through with the field experience semester the projects I have been working on are nearing completion. The only projects left are wrapping up of the data collected with TN radon, TV lobby, and Smokeout Day (which is Nov. 15). Looking back and seeing how far I have come since day one of my internship is really unbelievable. At the start of my internship I thought it would drag on forever and that I would get nothing accomplished. Now I can say that I was completely wrong, I have worked on numerous projects that not only helped me to complete my curriculum but also helped the community in one way or another and I feel like time has flown by and that I need more.

The date of our final presentation, when we show all that we have worked on, is approaching fast, and I can not be more excited and nervous all at the same time. I can not wait to show my fellow classmates and mentors all that has been done during my internship, but also to show them what a need there is in rural healthcare and communities.