Sunday, December 9, 2012


Jan's Day Trip from Bequia to Kingston, St. Vincent

Off for a day on my own, I boarded the ferry who's wake had rocked us regularly at our anchorage
in Bequia and an hour later arrived in Kingston, St. Vincents on a mission. The mission was to find another PT and broaden my understanding of medicine in the Caribbean. I couldn't have anticipated all the people I was going to meet in the course of my wanderings.

The boarding was so different than what I was accustomed to (Lake Champlain Transportation Company for instance).

The ferry lowered it's large boarding gate so vehicles could come aboard to find their place in the hold as the people filed in right along with them, paying for their tickets with a mate who neatly laid out the various types of tickets while unfurling his healthy wade of cash making change. I watched and went with the crowd trying to keep a lid on my wide-eyed expression over what OSHA had apparently missed during their last trip to the Caribbean. The ferry ride was an hour long and cost $45 EC for a round trip ticket.
Once aboard I climbed two flights of very narrow winding steps to the open air upper deck with a roof complete with holes for added ventilation. I soon found myself involved in conversation with another woman. She was a strikingly attractive woman with beautiful facial features, long arms and legs, excellent English, very simply dressed as everyone here seems to be and approximately my age. As the ferry started to move away from the shore we were well on our way to getting acquainted. One of the first things I learned from her was the ferry line gets their boats from Scandinavian countries. The unsaid part was that when the ferries won't pass inspection to Scandinavian standards, they're sold and utilized somewhere that isn't quite so fussy. The other bit that caught my attention was that they're original use was on rivers, which we certainly weren't traversing. The sailor in me took another immediate inventory, albeit too late, of the current sea conditions!
Hyacinth was a recently retired nurse practitioner who had work most of her professional life at the hospital in Bequia

(that I visited the day before this). Her education was provided by a world organization (forgot which) totally free. The program was set up in Kingston with the ultimate goal of handing it over a totally established program to the government here. Unfortunately, Hyacinth said that as soon as the funding was taken away the program died with all the education for mid level practitioners now taking place out of country, typically in Cuba, Sri Lanka or other countries. In the course of her career she was sent to multiple locations in the US and England for courses, typically part of organizations trying to promote understanding and enrichment of health care in the Caribbean. Her main focus on these sponsored trips was pulmonary medicine. We also swapped pictures of kids, war stories from work and bits about our cultures. Admittedly, my questions dominated but she was more than happy to comply. The Bequia hospital was eleven beds and more of a first aide station/maternity ward. Nurses are referred to as 'sister', a carry over from British rule times. To become a nurse you first need to be under 35 years of age and have met the educational requirements for admission typically to the nursing school in St. Vincents. When Hyacinth was working in the Bequia Hospital there was another nurse practitioner staffing it as well. They worked 24 hour shifts unless called in to back up the other nurse practitioner if she had to accompany a transfer to St. Vincents. Anyone moved to St. Vincent's went via ferry or plane with the nurse practitioner going along.
Care was one part of the conversation, even more interesting was the payment for that care. As in some other countries there are two systems here: private and public. Within the public area there is health care provided by the government for little or no cost to those individuals under 18, disabled and over 60. A surgeon, for instance, would work in both systems. Because the hospitals are owned by the government a surgeon would need hospital privileges to use the operating rooms, however the amount of time to wait for surgery would be very dependent upon the patient's ability to pay. If you were on the government plan it would be a few months or whatever, however if you had private insurance or the ability to pay cash it could be scheduled very soon. She related a number of instances that seems to suggest there was some double dipping going on as well.
Hyacinth shared with me that she traveled to Bequia once a week for an overnight stay with her aging parents. Her father had a problem that was diagnosed as ''probably due to arthritis''. It was surprising to me that she did not question the diagnosis after hearing the symptoms and rapidity of onset. But then again, an 87 year old man who was living in his home with his wife, happy and involved with his environment as she described him might be better off here with a slightly different approach (or even mis-diagnosis). Reminds me of a case presentation the Trauma Team at Carilion gave not too long ago concerning a 94 year old man who one could argue medicine didn't assist. I'd love to take that same group of professionals (surgeons, internists, nurses, residents, interns, PTs, OTs, chaplains, etc) and hear their comments on this case.
We swapped email addresses after finding out that I would be gone when she returned to Bequia next week. We said our good-byes, swapped emails and I was off into the throngs of people in Kingstown. John's comment that Kingstown would be as close to a Third World country as I had ever been in was entirely correct! This is the bus terminal.

And this is the cruise ship and ferry terminal.

Immediately upon disembarking the contrast was amazing. On the steep hillside going up from the terminal there was a broad spectrum of homes from small wooden shacks to very nice appearing masonry homes all nestled into the lush greenery of the island. To my right was a very modern cruise ship terminal complete with Welcome Center, finely manicured lawns, well tended plantings, various chickens and a HUGE cruise ship tied up to the wharf. Docked by the cruise ship was an island built double masted schooner very similar to the Friendship Rose in Bequia just unloading a large group of tourists following a sailing adventure complete with steel drum music. To my left was a mass of people manning rough built 8' x 8' wooden stalls selling all sorts of island fare (RUM, cold drinks, jewelry, crocheted hats of the Rastafarian sort, produce, etc), tons of taxis, cars, people walking next to cement ditches or around parked cars and heat from the pavement encouraging everyone to try to find a bit of shade. I made my way past the now familiar calls from the taxis to the tourist bureau. Once outside that building I was literally escorted to the second floor desk where I was given a good street map. This building was modern, beautifully kept with occupants who were smartly dressed and very well acquainted with how to treat a 'guest'. I'm reminded of the ''Niceness Training'' every employee and volunteer was put through at a HUGE hospital I worked at recently.
The walk to the hospital was about a mile through crowded streets. Along the way I passed a number of pharmacies so, remembering John's request for a medication, I ducked into one. In the back of the store I stepped thorough an open doorway and had arrived in the pharmacy- a man sitting at a desk with shelves behind him loaded down with medications. I asked for the generic form of plavix and was promptly given the two boxes containing 28 tablets each for $16 EC or about $6.50. Made in England. No prescription needed for any medications here other than narcotics.
By the time I neared the hospital the heat was pretty intense! So, just as if it was prearranged, an ice cream store appeared on the horizon.

It was also in an area that seemed like an oasis after walking thorough the crowded, dusty, littered city streets. There was a large Catholic church and school with a central garden that butted up against a lovely river, open to the public. The Catholic Church was ancient and quite Gothic Baroque looking with a definite whimsicalness to it.

It presented a great contrast with the heavy, block sort of architecture used to construct the Anglican Church across the street.

So I gladly made my way to the ice cream shop for a double dip and some time in a lovely air conditioned space before resuming my walk.
The hospital was, I'm guessing, a hundred beds.

I had two options: go to the administration and ask for permission to go in or follow the signs to the Physiotherapy Department. Since I didn't have time for another trip to Kingstown I decided to skip the administrative permission and head for the PT Department. I met Lena, a Philippine trained therapist, in the PT department. We visited and toured for over an hour. We talked about hospital services, what life on St. Vincents was like for she and her family and medicine in general. It was interesting! They see each patient about once every three weeks if they are on the government insurance plan. Many of the therapists, like the physicians, have a private practice plus work in the hospital. There is no neurosurgery, one orthopedic surgeon, an orthotist/prosthetist that comes up when there is enough demand from Barbados, no occupational therapy....and they lost half their department recently to a CT Scanner that was donated to the hospital. The CT Scanner was there to see in a room that looked pretty much like it was the PT Department. I wondered how much besides cement block was in the walls surrounding it. To all those of you who are PTs reading this I will pass on that the department was NOT in the basement.
So my day in Kingston was interesting and generated some friends that maybe I'll see again or maybe not. It was well worth the trip glimpsing into medicine in St. Vincents. After my hour long ferry ride back to Bequia it was nice to see John waiting on the dock to take me back to Elephant's Child. I took a longer shower than usual and slept well that night.

The Sunshine School in Bequia

Compass Magazine is a free publication directed at the yachting community here in the Caribbean. Reading through the November issue I noticed an article about a school here in Bequia for special needs children. Another yacht we were anchored by in Clark's Court Bay, Grenada was sited as visiting the school and spending some time volunteering. That seemed like something I might enjoy and further my understanding of medicine on the island so I was off to investigate.
After finding the school early one morning I walked back down to the waterfront for a cup of coffee at The Gingerbread Restaurant to wait for school to start. On my walk back I fell into conversation with another cruiser. She invited me to come along and help her pick out some batik, which I did, talking along the way about each of our adventures since arriving in Bequia. It wasn't long before she told me that she was a family practice physician in California here on a charter for a couple days with her husband, also a physician. As we left the batik store she asked me where I was going, at that point back to the school that should now be open. I asked her where she was going and the answer was ''With you. You're much more interesting than my husband''. We did have fun!
The Head Mistress at The Sunshine School, Mrs. Jacobs, invited me in to observe . The building was new, all funded by donations and fund raising efforts. Mrs. Jacobs had been involved with the school for 25 years, clearly taking a lot of pride in the facilities and opportunities it's creates for these children. The government gives them $1,500/ year EC (exchange rate is $2.65 EC to $1. US). I also met Jackie, a retired RN from Ohio who lives in Bequia, volunteering at the school six months of the year. The building was entirely made of cement with no windows (common here). The main meeting room was brightly colored and interesting in terms of what was there. Kids ranged in age from 7 to 19 and looked to be mainly cognitively impaired with some softer signs of physical impairment becoming evident after I watched them moving around and playing a bit of Simon Says. It's amazing what you can learn from a very simple game. School is free to any children who wish to come. Lunch is provided at a nominal cost to the child. Many of the children go on to middle or high school if the teachers think they can do the work. Interesting to see yet another piece of Caribbean culture, a far cry from services available to kids in the US.

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