Hyacinth E. Harding

Sedation for upper gastrointestinal endoscopy: a comparative study of midazolam and diazepam

Comparison of the ease of upper endoscopy, patient tolerance, and amnestic effect, using diazepam, midazolam, or no sedation, was performed on 149 patients. Midazolam and diazepam sedation produced better conditions and improved patient acceptability. Midazolam was associated with better patient tolerance, less thrombophlebitis, and more amnesia than diazepam, but shared a similar recovery time. Midazolam should replace diazepam as the drug of choice in those patients requiring sedation for upper endoscopy.

Microbial isolates from patients in an intensive care unit, and associated risk factors

A retrospective one-year analysis of blood, sputum and urine samples taken from all patients admitted for more than 48 hours to the Intensive Care Unit at the University Hospital of the West Indies (UHWI) was undertaken. Positive trapped sputum cultures were found in 50% of patients, positive blood cultures in 32.7% and positive urine cultures in 23.1%. Gram-negative organisms predominated especially Pseudomonas aeruginosa (41.3%) and Acinetobacter spp (33.5%). Coagulase-negative staphylococcus (20%) and streptococcus group D (18.7%) were the most common gram-positive organisms. The Acinetobacter spp showed marked resistance to most antibiotics except for meropenem (82.7% susceptibility) while P. aeruginosa was most susceptible to ceftazidime (84.4%) and amikacin (89.1%). Both the coagulase-negative staphylococcus and streptococcus group D were relatively sensitive to amoxycillin/clavulanate (80.6% and 79.3% respectively). There was a high incidence of yeast found in sputum (27.1%) and urine (16.8%). Mechanical ventilation was a significant risk factor for developing a positive sputum culture (p = 0.01), this effect being particularly prominent in those ventilated for > 5 days. Central venous pressure lines significantly increased the risk of a positive blood culture (p = 0.005). This increase was seen particularly in those with CVP lines for > 7 days. Other risk factors for developing positive cultures included preadmission infection, antibiotic use just prior to ICU admission, increasing APACHE II score and increasing age.

Motorcycle accident injury profiles in Jamaica: an audit from the University Hospital of the West Indies.

There is little data available on the prevalence of motorcycle accidents, their resultant injuries and the demand on the health care services in Jamaica. We performed a descriptive, analytical study to evaluate the extent of this problem and the need for preventative national policy measures. Between 1 January 2000 and 1 January 2007, demographic and clinical data on all motorcycle accident victims admitted to the University Hospital of the West Indies were collected in a prospective database. The data were analysed using the SPSS version 12.0. Of 270 motorcycle accident victims, there were 257 (95.2%) males and 13 (4.8%) females. Overall, 134 (49.6%) victims wore helmets at the time of their accident. The more common injuries were as follows: soft tissue trauma 270 (100%); head injuries 143 (53.0%); long bone fractures 126 (46.7%); abdominal injuries 38 (14.1%); thoracic injuries 71 (26.3%); vascular injuries 11 (4.1%). The mean injury severity score was 9.0 (SD 9.4; Median 8; Mode 4). There were 195 patients needing surgical intervention in the form of orthopaedic operations (94), neurosurgical operations (43), abdominal operations (49) and vascular operations (14). The mean duration of hospitalisation was 10 days (SD 11.2; Range 0–115; Median 6; Mode 3). There were 12 (4.4%) deaths, 9 (75%) due to traumatic brain injuries. Fatal injuries were more common in males (11) and un-helmeted patients (10). Motorcycle accidents take a heavy toll on this health care facility in Jamaica. Measures to prevent motorcycle accidents and reduce consequent injuries may be one way in which legislators can preserve precious resources that are spent during these incidents. This can be achieved through active measures such as educational campaigns, adherence to traffic regulations and enforcement of helmet laws.

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.

The prevalence of seat belt use in Kingston, Jamaica: a follow-up observational study five years after the introduction of legislation

An observational cross-sectional study conducted in Kingston in 2004 showed that seat belts were used by 81.2% of private motor vehicle drivers and 74.0% offront seat passengers. This was significantly improved compared to 21.1% and 13.6% respectively in 1996 before the introduction of legislation in 1999 (p < 0.001). Females were significantly more likely than males to wear seat belts, both when driving (92.5% vs 77.3%; p < 0. 001) and as front seat passengers (79.9% vs 66.3%; p < 0.001). Of the 2289 motor vehicles examined, all except one were equipped with seat belts. Rear passenger utilization of seat belts was not examined. Drivers of new vehicles were more likely than other drivers to use seat belts (p < 0.001). Male drivers, drivers of older vehicles and all passengers may require specific targeting in an educational and enforcement campaign if the maximum benefits of seat belt use are to be realized

Leadership in surgery for public sector hospitals in Jamaica: strategies for the operating room.

The barriers to health care delivery in developing nations are many: underfunding, limited support services, scarce resources, suboptimal health care worker attitudes, and deficient health care policies are some of the challenges. The literature contains little information about health care leadership in developing nations. This discursive paper examines the impact of leadership on the delivery of operating room (OR) services in public sector hospitals in Jamaica.Delivery of OR services in Jamaica is hindered by many unique cultural, financial, political, and environmental barriers. We identify six leadership goals adapted to this environment to achieve change. Effective leadership must adapt to the environment. Delivery of OR services in Jamaica may be improved by addressing leadership training, workplace safety, interpersonal communication, and work environment and by revising existing policies. Additionally, there should be regular practice audits and quality control surveys.

Revisiting Current Strategies for Primary Prevention of Motorcycle Collisions in Jamaica

Abstract Motorcycle Road Traffic Collisions place a heavy burden on emergency medical services in Jamaica. We explore the existing strategies and legislative policies that may prevent or reduce the severity of these injuries in Jamaica. This is an important aspect of health care as it may minimize the impact of these preventable injuries on the limited resources of the health services.

Triage decisions and outcome among the critically ill at the University Hospital of the West Indies

The worldwide scarcity of intensive care therapy leads to the rationing of this expensive resource. This prospective study investigates the rationing of intensive therapy at the University Hospital of the West Indies (UHWI) by recording triage decisions for intensive care unit (ICU) admission and the impact of these decisions on patient outcome. Between June 2001 and May 2002, all patients triaged for admission to a multidisciplinary ICU were studied For each patient, data were collected including APACHE II score, ICU resource availability and patient survival. There were 356 eligible requests, and 285 (80%) were admitted to the ICU, with 73 (26%) of these admitted patients receiving intensive care outside of the ICU due to space limitations. The APACHE II score was the strongest predictor of ICU admission, with admission more likely as the score decreased (odds ratio = 0.94, 95% confidence interval 0.91, 0.98, p = 0.001). Of 311 requests considered suitable for admission, 26 (8%) were refused admission due to resource limitations. Mortality among these eligible refusals was 81%, compared to 34% among admitted patients (p < 0.001). Although triage decisions are based predominantly on a patients disease severity, the demand for ICU space exceeds supply, and patient care is negatively impacted by this imbalance.

Complicated head trauma from machete wounds: the experience from a tertiary referral hospital in Jamaica

There have been limited reports on machete wounds to the cranium. This study was carried out to document the injury profile in a series of patients who have sustained cranial injuries from machete wounds in this setting. Between 1 January 1998 and 1 January 2008, demographic and clinical data were retrospectively collected from all patients treated with complicated head injuries from machete wounds with at least one of the following clinical or radiological features: a recorded Glasgow Coma Score < 8 at any point during admission; compound skull fractures; protruding brain matter; cerebrospinal fluid (CSF) leaks; intra-cranial bleeding; parenchymal contusions; lacerations and/or oedema. The data were analysed using the SPSS version 12.0. Of the 40 patients with complex injuries to the cranium, there was a 6:1 male preponderance with a mean age of 32.5 ± 13.7 years (Mean ± SD). The injuries included open skull fractures in all the 40 (100%) patients, depressed skull fractures in 20 (50%) patients, CSF leaks in 4 (10%) patients, protruding brain matter in 4 (10%) patients, cerebral contusions in 3 (7.5%) patients and extra cranial injuries in 16 (40%) patients. Tetanus prophylaxis and intravenous antibiotics were administered to all patients, and phenytoin was required in 16 (40%) cases. There were 37 (92%) patients requiring operative intervention at a mean of 10.4 h after presentation (SD ± 18.1; Median 6). The operative procedures included elevation of depressed fractures in 20 (54.1%) patients, dural repair in 10 (27.0%) patients and intra-cranial debridement in 7 (18.9%) patients. There were three deaths (7.5%), and seizures were recorded in 5 (12.5%) cases with no reports of infectious morbidity. Eighty percent of patients had a normal Glasgow outcome score on discharge. Complicated machete head trauma is uncommon at this health care facility in Jamaica. We achieved a satisfactory outcome with aggressive management consisting of prompt assessment of the extent of injury, appropriate antibiotics, anticonvulsants for those with seizures or cortical injury and early operation to decrease the risk of complications.

The impact of helmets on motorcycle head trauma at a tertiary hospital in Jamaica

BackgroundAlthough the Jamaica road traffic act mandates motorcycle riders to wear approved helmets, opponents suggest that the local road conditions obviate any benefits from helmet use that have been proven in Developed countries. They suggest that the narrow, winding, poorly surfaced, congested local highways do not allow motorcyclists to sustain high velocity travel. The accidents then tend to occur at lower speeds and are accompanied by less severe injuries. This study was carried out to determine the impact of helmet use on traumatic brain injuries from motorcycle collisions in patients admitted to a tertiary referral hospital in Jamaica.MethodsA prospectively collected trauma registry maintained by the Department of Surgery at the University Hospital of the West Indies in Jamaica was accessed to identify all motorcycle collision victims from January 2000 to January 2007. The therapeutic outcomes of traumatic brain injuries were compared between helmeted and un-helmeted riders. The data was analyzed using SPSS Version 12.ResultsOf 293 motorcycle collision victims, 143 sustained brain injuries. There were 9 females (6.3%) with an average age of 23 +/- 7.3 years and 134 males (93.7%) at an average age of 33.4 +/- 11.2 years (mean +/- SD). Only 49 (34.3%) patients wore a helmet at the time of a collision. Helmet use at the time of a collision significantly reduced the severity of head injuries (28.6% vs 46.8%, P = 0.028) and the likelihood of sustaining intra-cranial lesions (26.5% vs 44.7%, P = 0.03) from head injuries.ConclusionWearing a helmet at the time of a motorcycle collision reduces the severity of head injuries. However, the prevalence of helmet use at the time of a collision is unacceptably low.