Characteristics of patients requiring prolonged length of stay in a surgical intensive care unit in Barbados.

OBJECTIVE: To evaluate the clinical characteristics and costs incurred for patients who stayed for a prolonged period in a surgical intensive care unit (ICU). DESIGN AND METHODS: Data of all patients admitted to a surgical ICU in Barbados during the period of two years from July 1999 to June 2001 were prospectively collected. Demographic data, diagnoses on admission and Acute Physiology and Chronic Health Evaluation (APACHE II) score were recorded. Costs for treatment were calculated from using a cost block model. The characteristics of patients who had a prolonged stay (> 14 days) were compared with a concurrent cohort of patients who stayed less than 14 days. RESULTS: Of 438 admissions, 58 (13.2%) stayed in the ICU for more than two weeks. The overall age, hospital outcome, APACHE II scores in the prolonged stay group were significantly higher than that of the patients who stayed less than two weeks. Cost analysis showed about six times more expenditure in the long stay patients (dollar US 3800 vs dollar US 24000). Of the prolonged stay ICU patients, 29.2% would have required only a step-down unit due to less severity of illness as evidenced by their low mean APACHE II scores [7.3 +/- 2.6 (SD)] compared to overall mean APACHE II score 10.7 +/- 7.5 (SD). CONCLUSION: The study highlighted the need for a step-down unit and a protocol to transfer eligible patients to such a unit.

Knowledge, attitudes and practice of medical students at the Cave Hill Campus in relation to ethics and law in healthcare.

OBJECTIVES: The purpose of this study is to assess the knowledge, attitudes and practices among medical students in relation to medical ethics and law. The results of the study will be a useful guide to tutors of medical students and curricula designers. METHODS: A thirty-item self-administered questionnaire about knowledge of law and ethics, and the role of an ethics committee in the healthcare system was devised, tested and distributed to all levels of students and staff at the Queen Elizabeth Hospital in Barbados (a tertiary care teaching hospital) in 2003. The data from the completed questionnaires were entered into an SPSS database and analyzed using frequency and multiple cross-tabulation tables. RESULTS: Completed responses were obtained from 55 (96%) of the medical students. Medical students generally attested to the importance of ethical knowledge but felt that they knew little of the law. Students varied widely as regards the frequency with which they saw ethical or legal problems, with a quarter seeing them infrequently, but another quarter seeing them every day. They received their knowledge from multiple sources and particularly from lectures/seminars, and found case conferences the most helpful. Only a few students felt that text books had been helpful. Students were generally knowledgeable about most ethical issues, but many had uncertainties on how to deal with religious differences in treating patients, on the information to be given to relatives, and how violent patients should be treated. CONCLUSIONS: The results of the study highlight that medical students felt an inadequacy of knowledge of law as it pertains to their chosen career Since most of their knowledge of law was obtained from lectures, these should be reviewed and other avenues of tuition explored. The study also highlights the need to identify the minority of students who have problems with their ethical knowledge and to devise means whereby any deficiencies can be discussed and modified.

Knowledge, attitudes and practice of medical students at the Cave Hill Campus in relation to ethics and law in healthcare / Conocimientos, actitudes y prácticas de los estudiantes de medicina en el campus cave Hill en relación con la ética y las Leyes en el Campo de la Atención a la Salud

OBJECTIVES: The purpose of this study is to assess the knowledge, attitudes and practices among medical students in relation to medical ethics and law. The results of the study will be a useful guide to tutors of medical students and curricula designers. METHODS: A thirty-item self-administered questionnaire about knowledge of law and ethics, and the role of an ethics committee in the healthcare system was devised, tested and distributed to all levels of students and staff at the Queen Elizabeth Hospital in Barbados (a tertiary care teaching hospital) in 2003. The data from the completed questionnaires were entered into an SPSS database and analyzed using frequency and multiple cross-tabulation tables. RESULTS: Completed responses were obtained from 55 (96) of the medical students. Medical students generally attested to the importance of ethical knowledge but felt that they knew little of the law. Students varied widely as regards the frequency with which they saw ethical or legal problems, with a quarter seeing them infrequently, but another quarter seeing them every day. They received their knowledge from multiple sources and particularly from lectures/seminars, and found case conferences the most helpful. Only a few students felt that text books had been helpful. Students were generally knowledgeable about most ethical issues, but many had uncertainties on how to deal with religious differences in treating patients, on the information to be given to relatives, and how violent patients should be treated. CONCLUSIONS: The results of the study highlight that medical students felt an inadequacy of knowledge of law as it pertains to their chosen career Since most of their knowledge of law was obtained from lectures, these should be reviewed and other avenues of tuition explored. The study also highlights the need to identify the minority of students who have problems with their ethical knowledge and to devise means whereby any deficiencies can be discussed and...

OBJETIVOS: El propósito de este estudio es evaluar los conocimientos, las actitudes y la práctica entre los estudiantes de medicina en relación con la ética y las leyes en el campo de la medicina. Los resultados del estudio serán una guía útil para los tutores de los estudiantes de medicina y los diseñadores de currículos de estudios. MÉTODOS: Una encuesta auto-administrada de treinta puntos sobre los conocimientos de leyes y ética, y el papel de un comité de ética en el sistema de atención a la salud, fue diseñada, probada y distribuida a todos los niveles entre los estudiantes y el personal del Hospital Queen Elizabeth en Barbados (un hospital docente de atención terciaria) en 2003. Los datos de las encuestas completadas fueron introducidos en una base de datos de SPSS, y analizados usando tablas de frecuencia y tablas múltiples de tabulación cruzada. RESULTADOS: Se obtuvieron cuestionarios respondidos por parte de 55 (96%) de los estudiantes de medicina. Los estudiantes de medicina por lo general atestiguaron la importancia de los conocimientos éticos, pero sentían que sabían poco de las leyes. Hubo grandes diferencias entre los estudiantes con respecto a la frecuencia con que veían problemas éticos o legales – una cuarta parte de ellos señalando que no los veía frecuentemente, y otra cuarta parte indicando que los veía todos los días. Ellos recibieron sus conocimiento de múltiples fuentes – especialmente de conferencias y seminarios – y encontraron que las conferencias sobres casos, fueron las más útiles en tal sentido. Sólo unos pocos estudiantes fueron del parecer de que los libros de texto habían sido útiles. Por lo general, los estudiantes se mostraron conocedores de la mayoría de los problemas éticos, pero muchos manifestaron incertidumbre en cuanto a cómo abordar las diferencias religiosas al tratar con los pacientes, qué información dar a los familiares, y cómo debían ser tratados los pacientes violentos...

Characteristics of patients requiring prolonged length of stay in a surgical intensive care unit in Barbados / Características de los pacientes que requieren una prolongada estancia en una unidad quirúrgica de cuidados intensivos en Barbados

OBJECTIVE: To evaluate the clinical characteristics and costs incurred for patients who stayed for a prolonged period in a surgical intensive care unit (ICU). DESIGN AND METHODS: Data of all patients admitted to a surgical ICU in Barbados during the period of two years from July 1999 to June 2001 were prospectively collected. Demographic data, diagnoses on admission and Acute Physiology and Chronic Health Evaluation (APACHE II) score were recorded. Costs for treatment were calculated from using a cost block model. The characteristics of patients who had a prolonged stay (> 14 days) were compared with a concurrent cohort of patients who stayed less than 14 days. RESULTS: Of 438 admissions, 58 (13.2) stayed in the ICU for more than two weeks. The overall age, hospital outcome, APACHE II scores in the prolonged stay group were significantly higher than that of the patients who stayed less than two weeks. Cost analysis showed about six times more expenditure in the long stay patients (dollar US 3800 vs dollar US 24000). Of the prolonged stay ICU patients, 29.2would have required only a step-down unit due to less severity of illness as evidenced by their low mean APACHE II scores [7.3 +/- 2.6 (SD)] compared to overall mean APACHE II score 10.7 +/- 7.5 (SD). CONCLUSION: The study highlighted the need for a step-down unit and a protocol to transfer eligible patients to such a unit.

OBJETIVO: Evaluar las características clínicas y costos en que incurren los pacientes que permanecen un periodo prolongado de tiempo en una unidad quirúrgica de cuidados intensivos (UCI). DISEÑO Y MÉTODOS: Los datos de todos los pacientes ingresados en una UCI en Barbados durante el período de dos años de julio de 1999 a junio de 2001 de junio, fueron recopilados de manera prospectiva. Se registraron los datos demográficos, los diagnósticos al momento del ingreso, y la puntuación APACHE II. Se calcularon los costos del tratamiento mediante un modelo de bloques del costo. Las características de los pacientes que tuvieron una estancia prolongada (> 14 días) fueron comparadas con una cohorte concurrente de pacientes que permanecieron menos de 14 días. RESULTADOS: De 438 admisiones, 58 (13.2%) permaneció en la UCI por más de dos semanas. La edad general, el resultado hospitalario y la puntuación APACHE II fueron significativamente más altos en el grupo de estancia prolongada que en el de los pacientes que permanecieron menos de dos semanas. El análisis del costo mostró aproximadamente seis veces más gastos en relación con los pacientes de estancia prolongada ($3800 usd vs. 2 4000 usd). El 29.2% de los pacientes que tuvieron una estancia prolongada en la UCI, habrían requerido sólo un área de recuperación de fase II con una labor menos intensiva (step-down) debido al carácter menos severo de la enfermedad, tal cual lo pone de manifiesto la media baja de sus puntuaciones APACHE II [7.3 ± 2.6 (SD)] en comparación con la media general de la puntuación APACHE II (0.7 ± 7.5 (SD). CONCLUSIÓN: El estudio puso de relieve la necesidad de una unidad de recuperación de fase II (step-down) y un protocolo para transferir a los pacientes elegibles para esa unidad.

Outcome of elderly patients undergoing open-heart surgery in a developing country.

To evaluate and compare the outcome of open-heart surgery in elderly patients with a concurrent group of younger patients in a developing country, data of all adult patients who underwent open-heart surgery during the period of 3 years from January 1999 to December 2001 were collected prospectively. Demographic data such as age and gender, other data such as preoperative diagnoses, comorbid illnesses, type of surgery, time of cardio-pulmonary bypass, length of stay and hospital outcome were recorded. The characteristics of patients above the age of 65 years were compared with a concurrent cohort of patients aged less than 65 years. One hundred and forty-five adult patients underwent open-heart surgeries in 3 years, and the overall mortality rate was 4.8%. The much common surgeries were coronary artery bypass grafting, valve repair/replacement surgery and surgery for adult congenital heart diseases. Forty-five (31%) patients were above the age of 65 years. The mortality rate was 2.2% for patients who were aged 65 years and above, in comparison with that of the concurrent cohort of younger patients (6%). This was probably because of more number of surgeries for congenital heart diseases in the latter group. However, even with other surgeries such as coronary artery bypass grafting, the elderly group of patients did equally well as the younger group. Elderly patients tolerate cardiac surgery well, and age should not be an exclusive criterion to decide against open-heart surgery.

Outcome of elderly patients undergoing open-heart surgery in a developing country

To evaluate and compare the outcome of open-heart surgery in elderly patients with a concurrent group of younger patients in a developing country, data of all adult patients who underwent open-heart surgery during the period of 3 years from January 1999 to December 2001 were collected prospectively. Demographic data such as age and gender, other data such as preoperative diagnoses, comorbid illnesses, type of surgery, time of cardio-pulmonary bypass, length of stay and hospital outcome were recorded. The characteristics of patients above the age of 65 years were compared with a concurrent cohort of patients aged less than 65 years. One hundred and forty-five adult patients underwent open-heart surgeries in 3 years, and the overall mortality rate was 4.8 per cent. The much common surgeries were coronary artery bypass grafting, valve repair/replacement surgery and surgery for adult congenital heart diseases. Forty-five (31 per cent) patients were above the age of 65 years. The mortality rate was 2.2 per cent for patients who were aged 65 years and above, in comparison with that of the concurrent cohort of younger patients (6 per cent). This was probably because of more number of surgeries for congenital heart diseases in the latter group. However, even with other surgeries such as coronary artery bypass grafting, the elderly group of patients did equally well as the younger group. Elderly patients tolerate cardiac surgery well, and age should not be an exclusive criterion to decide against open-heart surgery.

Performance measurement of intensive care services in hospitals: the case of Barbados

The Intensive Care Unit (ICU), being one of those vital areas of a hospital providing clinical care, the quality of service rendered must be monitored and measured quantitatively. It is, therefore, essential to know the performance of an ICU, in order to identify any deficits and enable the service providers to improve the quality of service. Although there have been many attempts to do this with the help of illness severity scoring systems, the relative lack of success using these methods has led to the search for a form of measurement which would encompass all the different aspects of an ICU in a holistic manner. The Analytic Hierarchy Process (AHP), a multiple-attribute, decision-making technique is utilised in this study to evolve a system to measure the performance of ICU services reliably. This tool has been applied to a surgical ICU in Barbados; we recommend AHP as a valuable tool to quantify the performance of an ICU.

Outcome evaluation in a surgical intensive care unit in Barbados.

The performance of the Acute Physiology and Chronic Health Evaluation II scoring system was prospectively assessed in the surgical intensive care unit at the Queen Elizabeth Hospital, Barbados. A total of 309 patients admitted consecutively during a 2-year period (1999-2001) were evaluated. Demographic data, diagnosis, Acute Physiology and Chronic Health Evaluation II score, duration of stay and hospital outcome were recorded. The predicted mortality for every patient and the costs incurred were also calculated. The overall observed mortality rate was 15.9% while the mean predicted mortality rate for our case-mix was 16.4%, which is comparable to results from developed countries. The cost incurred per patient was much lower at $13,636 (Barbados), compared to the patients' cost in North America ($60,000 Barbados).

Anesthesia outside the operating room for emergency procedures.

Non-anesthetists usually provide sedation and anesthesia outside the operating room for emergency procedures. Techniques vary from no sedation to deep sedation using drugs with a good safety profile and few side effects. Newer methods of airway control may allow volatile agents such as sevoflurane to be used. Anesthetists may need to join sedation teams if they are to maintain control of their specialty.

Anaesthesia in Barbados.

PURPOSE: To describe the anaesthesia services in Barbados: to present the major challenges confronting the Anaesthesia Department of the government-owned Queen Elizabeth Hospital (QEH): and to describe the Department's approaches to optimise safety and cost-effectiveness of anaesthesia at QEH. SOURCE OF INFORMATION: Authors (KBS, HSLM, RAH), who collectively provided more than 50 yr of anaesthesia at QEH; the Dean (ERW) of the University of West Indies Medical School (Barbados campus); archives of Barbados; and records of QEH. PRINCIPAL FINDINGS: The government of Barbados provides modern health care services to all of its citizens, primarily at QEH. Barbados, however, has tight financial constraints, infrastructural limitations, and a bureaucratic administration that predispose QEH's Anaesthesia Department to unexpected depletions of drugs and disposable supplies, sporadic shortages of personnel and functioning equipment, and occasional quality assurance problems. To deal with such problems, the Anaesthesia Department has implemented several pro-active measures: establishing an audit system to prevent depletion of imported drugs and supplies: training local personnel to maintain equipment: purchasing an oxygen concentrator to reduce oxygen costs: decreasing nitrous oxide use (expensive in Barbados): and initiating its own quality and safety standards. CONCLUSION: Continuous delivery of high quality, cost-effective anaesthesia care requires thoughtful planning by administrators and judicious resource allocations. Health care administrators and clinical departments need to work together closely to establish a framework that enables departments to play a major role in determining how the institution's limited financial resources are best allocated to meet the departmental priorities.

The role of stereotactic biopsy in assessment of nonpalpable breast lesions.

BACKGROUND: When mammography identifies a lesion suspicious for cancer, stereotactic needle core biopsy (SCNB) and needle localization (NL) surgical biopsy are options for obtaining tissue. This study compared the results of these two biopsy methods in evaluating nonpalpable radiologically suspicious breast lesions. METHODS: Records of 292 women who underwent SCNB or surgical biopsy at two institutions were reviewed over 28 months. The women were separated into two groups, under 50 years of age and 50 years of age and older. RESULTS: A total of 70 women over the age of 50 had stereotactic biopsy. One hundred and three had NL biopsies. The rate of positivity was 37% and 33% for stereotactic and NL biopsy respectively (P = 0.693). A total of 44 women under the age of 50 had stereotactic biopsy. Seventy had NL biopsies. The rate of positivity was 7% and 21%, respectively, for stereotactic and NL (P = 0.082). NL surgical biopsy costs on average $2354.00. SCNB averages $949 including follow-up mammogram. CONCLUSION: SCNB is a cost-effective, accurate method of breast biopsy. This report retrospectively compares SCNB with surgical open biopsy aided by NL. The cost savings occurred primarily in surgeon's fees and anesthesia fees. We found no statistical difference in < 50- or > 50-year-old patients in the frequency of the diagnosis of breast cancer when comparing the two types of biopsies.

Anaesthetic management of a child with Bartter's syndrome.

We report the anaesthetic management of an eight-year-old asthmatic boy with Bartter's syndrome who had bilateral orchidopexy with caudal epidural analgesia. Bartter's syndrome is a rare congenital disorder characterized by hypokalaemic hypochloraemic metabolic alkalosis, hyperaldosteronism, hyperreninaemia and hyperplasia of the juxtaglomerular apparatus of the kidneys. Characteristically, although these patients are normotensive they may be hypovolaemic. They may have unstable baroreceptor responses and show marked resistance to vasopressors. Hence, fluid, acid-base and electrolyte imbalances along with haemodynamic instability pose particular problems in their anaesthetic management. Previous case reports have described the management of these patients with general anaesthesia, our patient had his orchidopexy with caudal epidural analgesia using plain bupivacaine 0.5%. The patient was haemodynamically stable throughout surgery and was comfortable with caudal analgesia as the sole anaesthetic. Hypovalaemia, acid-base status and electrolyte imbalance were treated before instituting caudal epidural analgesia. We present this case report which describes the anaesthetic considerations in the light of the pathophysiology of Bartter's syndrome.

Terminology and the current limitations of time capnography: a brief review.

The carbon dioxide (CO2) trace versus time (time capnography) is convenient and adequate for clinical use. This is the method most commonly utilized in capnography. However, the current terminology in time capnography has not yet been standardized and is, therefore, a potential source of confusion. Standard terminology that is based on convention and logic to represent the various phases of a time capnogram is essential. The time capnogram should be considered as two segments: an inspiratory segment and an expiratory segment. The inspiratory segment is termed as phase ); the expiratory segment is divided into phases I, II, III, and, occasionally, IV. Phase I represents the CO2-free gas from the airways (anatomical dead space); phase II consists of a rapid S-shaped upswing on the tracing due to mixing of dead space gas with alveolar gas; and phase III, the alveolar plateau, represents CO2-rich gas from the alveoli. The physiologic basis of phase IV, the terminal upswing at the end of phase III, which is observed in capnograms recorded under certain circumstances (such as in pregnant subjects and obese subjects) is discussed in detail. The clinical implications of the alpha angle, which is the angle between phases II and III, and the beta angle, which is the angle between phases III and the descending limb of phase 0, are outlined. The subtle but important limitations of time capnography are reviewed; its current status as well as its future potential are explored.

Leiomyoma of the seminal vesicle.

Leiomyoma of the seminal vesicle is exceedingly rare, with only a few cases reported in the literature. To our knowledge we present the first case of primary leiomyoma of the seminal vesicle to be evaluated by magnetic resonance imaging using a rectal coil.

Inspiratory valve malfunction in a circle system: pitfalls in capnography.

Capnography is a useful technique in monitoring the integrity of anaesthetic equipment such as the malfunctioning of unidirectional valves in circle system. However, the lack of a precise mechanism in existing capnographs to identify the start of inspiration and the beginning of expiration in the capnograms, makes the analysis of the carbon dioxide waveforms during inspiration difficult and thus results in inaccurate assessment of rebreathing. We report a case where, during the malfunction of the inspiratory unidirectional valve in the circle system, the capnograph failed to detect the presence of substantial rebreathing. Critical analysis of the capnogram recorded during the malfunction revealed that there was substantial rebreathing which was underestimated by the capnograph as it reports only the lowest CO2 concentration rebreathed during inspiration in such abnormal situations.

An evaluation of two methods of limb salvage in extremity soft-tissue sarcomas.

Between 1983 and 1990, 38 sequential patients with stage II to III soft-tissue sarcoma of the extremities, as defined by the American Joint Committee on Cancer, were treated. Eighteen patients were treated with intra-arterial doxorubicin hydrochloride, limb salvage surgery, and radiation (group A). Twenty patients in group B were treated with cisplatin, isolated limb perfusion, limb salvage surgery, and radiation. The study was not randomized, but all patients were treated prospectively using one of the two protocols. The two groups were similar demographically and had similar lengths of survival without disease. There was only one local recurrence in the series, and this occurred in a group B patient who underwent perfusion with the lowest dose of cisplatin. Regional perfusion with either intra-arterial doxorubicin hydrochloride or cisplatin combined with limb salvage surgery and postoperative radiation are highly effective in preventing local recurrences and preserving functional extremities in patients with soft-tissue sarcoma. There was no difference in results between these two methods.

Anaesthesia without nitrous oxide

Nitrous oxide has a long history of successful use in inhalational anaesthesia. Nevertheless questions are being raised over possible deleterious effects which may complicate its routine use. As more potent volatile agents have become available, compressed air/oxygen mixtures are gradually replacing nitrous oxide as a carrier gas in inhalational anaesthesia. We recommend that compressed air be installed on all anaesthetic machines and that in future, machines be designed so as to make it impossible to administer both nitrous oxide and air simultaneously (AU)