Ew Williams

The HIV/AIDS epidemic in Jamaica

ObjectiveTo describe the HIV/AIDS epidemic in Jamaica. MethodsData from the national surveillance system for HIV infection and AIDS based in the Epidemiology Unit, Ministry of Health, were reviewed. These include case reports; HIV screening of blood donors, migrant farmworkers and US visa applicants; sentinel surveillance among antenatal clinic (ANC) attenders and sexually transmitted disease (STD) clinic attenders; and various serosurveys. ResultsA total of 669 AIDS cases were reported in Jamaica from December 1993 representing a cumulative AIDS case rate of 28 per 100000 population. Since 1987 the annual AIDS case rate doubled every 2 years with 69% of individuals having died with AIDS. Heterosexual transmission predominates with the cumulative adult AIDS male-to-female case ratio declining from 2.8:1 in 1988 to 1.9:1 in 1993. A total of 55 children with AIDS account for 8.2% of all cases. The HIV infection rate per 1000 in 1993 was 3.8 among blood donors, 1.4 among ANC attenders and significantly higher among STD clinic attenders (men 6%, women 2.7%), homosexuals (9.6%), female prostitutes (12%) and individuals with repeat STD infections (10%). Consistent condom use increased from 27% in 1989 to 47% in 1993. ConclusionsHIV infection was introduced into Jamaica from abroad through several different routes including the Jamaican homosexual community, migrant farmworkers, female prostitutes, and informal commercial importers. HIV transmission is well established locally and is spreading more rapidly in Western Jamaica and along the North Coast, which may reflect increased sexual activity associated with tourism. Although awareness of AIDS and HIV is high and condom use has increased considerably, there are no grounds for complacency concerning the HIV/AIDS epidemic in Jamaica.

Colonic perforation: a lethal consequence of cannabis body packing.

Body packing is one method of smuggling cannabis across international borders. The practice is prevalent in Jamaica. There has been one reported death from this practice in medical literature. We report a second fatal case of cannabis body packing, reinforcing the dangerous nature of this practice.

Emergency department physician training in Jamaica: a national public hospital survey

BackgroundEmergency Department (ED) medical officers are often the first medical responders to emergencies in Jamaica because pre-hospital emergency response services are not universally available. Over the past decade, several new ED training opportunities have been introduced locally. Their precise impact on the health care system in Jamaica has not yet been evaluated. We sought to determine the level of training, qualifications and experience of medical officers employed in public hospital EDs across the nation.MethodsA database of all medical officers employed in public hospital EDs was created from records maintained by the Ministry of Health in Jamaica. A specially designed questionnaire was administered to all medical officers in this database. Data was analyzed using SPSS Version 10.0.ResultsThere were 160 ED medical officers across Jamaica, of which 47.5% were males and the mean age was 32.3 years (SD +/- 7.1; Range 23–57). These physicians were employed in the EDs for a mean of 2.2 years (SD +/- 2.5; Range 0–15; Median 2.5) and were recent graduates of medical schools (Mean 5.1; SD +/- 5.9; Median 3 years).Only 5.5% of the medical officers had specialist qualifications (grade III/IV), 12.8% were grade II medical officers and 80.5% were grade I house officers or interns. The majority of medical officers had no additional training qualifications: 20.9% were exposed to post-graduate training, 27.9% had current ACLS certification and 10.3% had current ATLS certification.ConclusionThe majority of medical officers in public hospital EDs across Jamaica are relatively inexperienced and inadequately trained. Consultant supervision is not available in most public hospital EDs. With the injury epidemic that exists in Jamaica, it is logical that increased training opportunities and resources are required to meet the needs of the population.

Association between exposure/non-exposure to the mandatory seat belt law with regards to compliance in vehicle accident victims: a hospital review

OBJECTIVE Injuries sustained in motor vehicle accidents (MVAs) are a major challenge to the Jamaican healthcare system. In November 1999, Jamaica enacted legislation to make seat belt usage in motor vehicles compulsory. The effect of this policy change on seat belt usage is unclear. This study therefore sought to determine the prevalence of seat belt usage and to determine the association between exposure/non-exposure to the mandatory seat belt law and seat belt use in subjects who presented to the Accident and Emergency Department (A&E) of the University Hospital of the West Indies (UHWI) as a result of motor vehicle accidents. METHODS Subjects were recruited from June to November 2003, post-seat belt law (POBL) period, and May to October 1999, pre-seat belt law (PRBL) period. Data collected included demographic variables, seat belt use and position of the occupants in the vehicle. RESULTS Of the 277 patients who were eligible for inclusion, data were complete in 258 subjects, 87 in the PRBL period and 171 in the POBL period. The prevalence of seat belt use was 47% (PRBL) and 63% (POBL) respectively. There was no significant gender difference at each period. The odds of wearing seat belt in the rear of a motor vehicle were significantly lower than that of a driver (Table 3, OR 0.19, 95% CI 0.07, 0.48). Adjusting for age, gender and position in vehicle exposure, there was about 100% increase in the odds of seat belt use during the post seat belt law era (OR = 2.09, 95% CI 1.21, 3.61). CONCLUSION It is concluded from this hospital-based study that the mandatory seat belt law legislature was associated with increased seat belt use in motor vehicle accident victims. However, current data from the Road Traffic Agency indicate that there is still an alarming number of fatalities. This clearly suggests that additional public health measures are needed to address the epidemic of motor vehicle trauma in Jamaica.

Laparoscopic inguinal hernia repair in a developing nation: Short-term outcomes in 103 consecutive procedures

Background: There are no published data on the outcomes of inguinal hernia repair from the Anglophone Caribbean. To the best of our knowledge, this is the first report of a series of laparoscopic inguinal hernia repairs from the region. Materials and Methods: Data was extracted from a prospectively maintained database of consecutive trans abdominal pre-peritoneal (TAPP) repairs done between June 1, 2005 and May 30, 2012. Perioperative data collected included patient demographics, hernia type, operative technique, duration of surgery, intra-operative details, morbidity, analgesia requirements, and duration of hospitalization. A telephone survey was also performed to identify late recurrences and complications. Descriptive statistics were generated using Statistical Package for Social Sciences (SPSS) Ver 12.0. Results: There were 103 consecutive TAPP procedures in 88 patients at an average age of 35.4 years ± 12.9 (standard deviation; SD) and average body mass index (BMI) of 28.9 Kg/m 2 ± 2.23 (SD). The indications were bilateral (30), recurrent unilateral (24), and primary unilateral (49) inguinal hernias. The mean duration of operation was 68.5 minutes (SD ± 10.4; Range: 55-95; Median 65; Mode 65) minutes for unilateral TAPP and 89 minutes (SD ± 7.61; Range: 80-105; Median 90; Mode 90) for bilateral repairs. Post-operatively, 65/70 patients required ≤1 dose of parenteral opioid analgesia and 74 (84.1%) patients discontinued oral analgesia within 48 hours of operation. Complications were recorded in six (5.8%) cases and a recurrence in one (0.97%) case after a mean follow-up period of 3.2 years (SD ± 1.8; Range: 0.5-7). Conclusion: Laparoscopic inguinal hernia repair is a safe and effective operation in this setting.

Occupational hazard: Treating cocaine body packers in Caribbean countries

Body packing is a common method of smuggling cocaine where individuals ingest several drug-filled parcels for transport. When identified by the authorities, body packers are usually taken to hospital for evaluation. There are several points during management of these patients when the health care team may be placed at risk. We explore the hazards encountered during the management of these patients in developing Caribbean nations.

Inter-hospital transfer of trauma patients in a developing country: A prospective descriptive study

UNLABELLED There is no standardised protocol for the transfer of injured patients in Jamaica, a process that is well known to be potentially hazardous. We undertook this study to evaluate the inter-hospital transfer process of injured patients in this developing country. MATERIALS AND METHODS A prospective descriptive analytical study of all consecutive patients transferred to the University Hospital of the West Indies from other hospitals was conducted over six months. Data were collected on specially designed proformas and analysed using SPSS version 10.0. RESULTS Of 122 patients studied, 79.5% were male and the mean age was 27.8+/-20.7 years. Most injuries resulted from road traffic accidents (40.2%), falls (27.1%) and assaults (26.2%). Several problems with the transfer process were identified. There was poor documentation of clinical parameters at referring institutions, with records of pulse rates in 13.1% (16/122), blood pressure in 9.8% (12/122), respiratory rate in 9.8% (12/122), Glasgow Coma Score in 10.6% (13/122) and pupillary reaction in 4.9% (6/122) of cases. Transfer arrangements were made by junior medical officers in 93.4% (114/122) of cases while consultants requested only 3.3% (4/122) of transfers. Public hospital ambulances transported 91.8% (112/122) of patients and 7.4% (9/122) were transported by helicopter. These vehicles were equipped with facilities for oxygen administration in 99.2% (121/122) of cases and sphygmomanometers in 91% (111/122) of cases, but functional capacity for suction was only present in 50% of vehicles. These critically ill patients were accompanied by physicians in only 11.5% (14/122) of cases, while 68.9% (84/122) were accompanied only by nurses. CONCLUSIONS The transfer of injured patients is not being performed in a manner consistent with modern medical practice. There is urgent need for implementation of a standardised protocol for the transfer of such patients in Jamaica.

EMS response to an airliner crash

This report of an aircraft crash at a major airport in Kingston, Jamaica examines the response of the local Emergency Medical Services (EMS). Factors that impacted the response are discussed, and the need for more disaster simulation exercises is highlighted. The objective of this case report was to document the response of EMS personnel to the crash of American Airlines Flight 331, and to utilize the information to examine and improve the present protocol. While multiple errors can occur during a mass-casualty event, these can be reduced by frequent simulation exercises during which various personnel practice and learn designated roles. Efficient triage, proper communication, and knowledge of the roles are important in ensuring the best possible outcome. While the triage system and response of the EMS personnel were effective for this magnitude of catastrophe, more work is needed in order to meet predetermined standards. Ways in which this can be overcome include: (1) hosting more disaster simulation exercises; (2) encouraging more involvement with first responders; and (3) strengthening the links in the local EMS system. Vigorous public education must be instituted and maintained.

Management and Treatment of Pelvic and Hip Injuries

The management of pelvic fractures and hip injuries requires a multidisciplinary approach and begins in the prehospital setting. With the current advances in various investigative modalities along with the use of algorithms, the morbidity and mortality from these injuries has improved. This review discusses an outline of the current recommendations along with treatment strategies and options in the emergency department, which may vary from institution to institution based on the availability of expertise and resources and because no two trauma patients are alike with regard to the pathophysiology and injury patterns.

Penetrating neck trauma and the aberrant subclavian artery

Vascular injuries from penetrating trauma to the base of the neck are accompanied by significant morbidity and potential mortality. These injuries require several diagnostic adjuncts in order to facilitate early diagnosis and appropriate treatment. Herein reported is the case of a patient who sustained penetrating injury to the thoracic inlet but had a fortuitous anomaly that prevented vascular injury and its attendant complications.