Ehi Okpe
Queen Elizabeth Hospital, Barbados, Bridgetown, Barbados

Barbados is the most Eastern Island in the Caribbean measuring 166 square miles, with a population is approximately 300,000 people. Temperatures on the island range from 27ºC to 33ºC depending on the time of year. It is a very politically stable country and has been ranked by the United Nations as the world’s number one developing countries in the world. The Barbadian economy is based mainly on tourism, business/financial services as well as agriculture and manufacturing. With all these credentials, Barbados seemed like a great destination for my elective.

The Hospital
The healthcare provided in Barbados is mainly privately based with few state-owned clinics (known as polyclinics). The main public hospital is the Queen Elizabeth Hospital in the capital, Bridgetown. The hospital looks after approximately 7,000 patients with a range of medical problems. As a result, outpatient clinics are extremely busy with over 30 patients waiting to be seen in just one clinic, which is usually run by only one consultant and his team. Most specialities only have one consultant working in a particular department, except those specialities where there is a high turnover of patients, eg obstetrics and gynaecology and ophthalmology.

My experiences
General medicine – endocrinology and diabetes team
During my elective, I spent time working under the general medical team with the lead consultant specialising in endocrinology and diabetes and in the ophthalmology department. I split my time equally between the two specialities so I could gain more knowledge and understanding of what these jobs entailed as well as seeing pathology I had only seen in textbooks. The first four weeks I spent with the consultant diabetologist and endocrinologist and the rest of his team. We split our time between endocrinology clinics, ward rounds and diabetes clinic each week. The first activity we were involved in was the ward round. This is a strange concept as it doesn’t involve just seeing patients on one ward but on most of the wards in the hospital. Our team were looking after about 30 patients dotted around six wards, so ward rounds often took up to four hours to complete.

Even from the first few days of my elective, it was very apparent that diabetes is generally not well understood in Barbados. This is despite the fact that nearly 20% of the population are affected by it. There is no community-based organisation for patients with diabetes so most patients are treated in the hospital or at private GP clinics. There are also no screening programmes for diabetic retinopathy or diabetic foot and it isn’t safe to assume that patients who are seen by a family doctor are checked over for the complications of diabetes. It is well-known that patients, who have diabetes and are admitted into hospital for whatever problem, are much more likely to leave the hospital without a limb. Surgeons don’t often wait for leg ulcers to heal, preferring to remove limbs sooner rather than later. The removal of limbs in the hospital is so common that the details of what items belong in clinical waste even include limbs. People in Barbados are not aware of how diabetes affects others, despite the efforts of local charity organisations trying to raise the profile of this disease and with Afro-Caribbean people at a higher risk of developing this disease, it has never seemed more urgent for Barbadians to know the dangers and for diabetic patients to take their control of their treatment and lifestyle. This is easier said than done in a place notorious for its laid-back approach to life in general.

I only got to see a snippet of what the diabetic services are like in the hospital after spending a few days in clinic. Diabetic clinic takes place on a Monday morning and there are usually 20 patients to see. The consultant oversees the work of his juniors but reviews all the patients himself so he is very busy. Up until last year, the clinic didn’t have its own Diabetic Specialist Nurse but after finding a nurse willing to take on the workload, our consultant trained her and she sees patients to review. The only battle she has is trying to convince patients that they needed to wear better footwear than flip-flops.

Unfortunately the consultant was seeing more and more young patients coming to the clinic with Type II Diabetes. They are usually sent to clinic so they can be monitored more closely by a specialist. This problem highlighted the need for a more community-based diabetic service with other integrated specialities that dealt with diabetic complications and diabetes in young patients. The consultant felt this was the way forward in tackling diabetes in Barbados and by the end of my elective he had devised a plan of the service he wanted to implement and was presenting this to Barbadian Health Authority and sponsors who would fund the project. I hope his proposal was successful.

Ophthalmology
After my general medicine rotation, I spent three weeks in the ophthalmology department. Due to the nature of my course in the UK, I hadn’t spent much time doing ophthalmology or examining patients with eye pathology. The only eye pathology I had really seen was conjunctivitis, so I was excited to spend some time in clinics and observing eye surgery. Clinics in the ophthalmology department run everyday, with morning and afternoon clinics. The department is one of the busiest in the hospital and clinics often over-run due to the sheer volume of patients. Commonly, patients that are seen have diabetic retinopathy, hypertensive retinopathy, cataracts or glaucoma, all of which are advanced as patients do not present early enough.

I participated in all the clinics I attended and managed to use my ophthalmoscope on all the patients that came to clinic. For once, I actually saw what grade of diabetic retinopathy patients had and was able to actually say what features I could see, so hopefully I can apply this experience to patients that I see in the UK. I spoke to a lot of patients with cataracts and diabetic retinopathy. One of the patients I met who had proliferative diabetic retinopathy of both eyes. Unfortunately this patient sustained a haemorrhage at the back of the right eye and despite emergency laser treatment, was left blind in his right eye as the damage was too extensive. Despite this, his diabetic control was still very poor and he was only checking his blood glucose levels once a week and he was now requiring laser treatment to the other eye. The consultant referred him to the diabetic clinic to start him on insulin therapy to help save the vision of his left eye. I don’t think this patient understood how poor the prognosis was for his remaining eye and seemed to fleetingly take on board what the consultant said about the need for good sugar control. I can’t remember the number of patients he said this to but their response were the same; smile and say yes but these patients would be back in clinic with blurred vision and complete visual loss in one eye due to uncontrolled diabetes. “You don’t have diabetes for a day, it’s for life. You have it all the time and therefore you need to control your blood sugar every day” my consultant would say to all his diabetic patients, knowing that they would do it for a while but revert back to their old ways till he saw them in clinic again. I can imagine how frustrating it feels to be constantly telling patients the same things but the consultant explained that if he didn’t say something to the patients, then nobody would.

Apart from clinic work, I spent some time in theatre watching cataract operations. They are very finite operations and require a lot of manual dexterity. Most cataract surgery takes about fifteen minutes and the majority of patients go home the same day and are reviewed in clinic a few weeks later. I was surprised how high-tech the equipment was and how well the theatre staff kept the surgical area. Unfortunately I didn’t get to assist in any of the operation but they were still rewarding to watch nonetheless.

Final thought
I thoroughly enjoyed my elective in Barbados. Besides the beautiful weather, stunning beaches and the warm and friendly people, I also saw and learnt a lot of medicine. The medical system has its problems but then so do most medical systems across the world. They are a few years behind some of the standards of the hospitals in the UK but the enthusiasm to reach for higher standards can be felt across the hospital. There are large obstacles to climb to ensure that patient care is given to a good standard but the failings can be costly as I have seen. Nevertheless the doctors that practise in Barbados are making sure that these obstacles are reduced and those patients that can’t afford to pay for healthcare get the best available care that can be given.

Ehi Okpe 2008