Posted on August 1, 2018
By Dr. Beauty Sandhu
“Guyana? Is that in Africa?”
“No, it’s a country in South America, but it’s considered Caribbean by culture.”
This is usually how the conversation starts with people who ask about my international elective in February-March, 2018.
I landed at Cheddi Jagan International Airport in Guyana on a bright and beautiful Sunday morning and picked up my luggage from a very small terminal. It was warm—a stark contrast to the weather I left behind in southern Alberta. As I exited the terminal I saw a seating area with white plastic seats.
“Ma’am, do you need a taxi?”
“No thank you, I have a driver coming to pick me up.” I realized I should probably call the resident physicians, who had been there for a week, to see if that driver was on his way.
As I started walking over to the seating area another taxi driver asked me if I had a ride and followed up with “are you from Trini?” “Nope, I’m Canadian” I said with a smile, knowing that it would probably confuse him.
I sat down, got out my phone and called my friend (and brother’s fiancé), Tania, and asked if she knew where the driver was. She wasn’t sure but forwarded me his number. The driver and his sons would be our trusted drivers during our electives. While I waited for one of his sons to arrive, I took in the scene in front of me.
Hanging from the arrivals terminal was the green, yellow, red, white and black Guyanese flag wavering in the light breeze. There seemed to be a mix of African and Indian people waiting at the arrivals gate. I people watched for a little while and looked at my text history with Tania. I scrolled up to remind me of the names of the other 3 resident physicians that were living at the house we were sharing—Steve, Jesse and Laura. I had met Laura before on a girls’ trip to Banff and was excited to meet the other two.
The driver called me and picked me up. Finally! I couldn’t wait to have a nap when I got to a bed. On the way to the residence, the driver apologized for his brother’s mistake and showed me many of the attractions in the city of Georgetown. The Banks beer and El Dorado rum distilleries, the Demerara River with a glimpse of one of the longest floating bridges in the world, the Stabroek market and St. George’s Cathedral were some of the many attractions he pointed out on our drive.
We arrived at a gated home, which reminded me of my family’s home in India. I called Tania and she appeared at the door with her pretty smile and cute sundress.
I was introduced to my new housemates but was too tired to remember my first impressions of them. I made my way upstairs to the large room with wooden floors and two beds. Tania and I were to share this room for the next three weeks. I opened up my suitcase right away and took out two white mosquito nets.
“Mom bought two! One for you and one for me!”
We put up our mosquito nets and then giggled as we sat under them. We were mosquito net princesses.
I went through my backpack and decided to hand out the Valentine’s Day cards to my new housemates, along with some chocolates (I know, I’m a nerd like that). With that I took a nap for a few hours and was later awoken by Tania. “Beauty, the taxi’s here!” The rest of the group had planned an outing to Pandama Retreat and Winery. It was a wonderful time with hammocks, a pond, some fruit wine and great food but better company. I was exhausted but relaxed. Plus, if I hadn’t gone I would have had major FOMO, and that’s not a way to start off any adventure! I slept like a baby that night in the AC…and tomorrow was going to be my first day on the Internal Medicine floor.
We walked to the Georgetown Public Hospital in the morning in six minutes with kissing noises coming from some of the men on the streets and many stray dogs that would catch Jesse’s attention. We got to the hospital and entered through an entrance with multiple glass windows and little Guyanese flags outside the front. We climbed some stairs and made our way to the third floor, where the resident physicians room was. The nurses were in white uniforms and the air was musky. We crowded into the resident physicians room, which had two computers, a bunk bed, and multiple chairs with whiteboards around the walls. I was going to be on Team Purple and had no idea what was going to be expected of me from this week.
We started rounds and things initially felt the same as they would rounding anywhere else. The attending was a little late, the medical students looked confused but eager, there was shuffling of papers and chaos. The senior was tired, as my team was on call the night before. It had been a relatively quiet night I heard. We saw our first patient, a 76 year old woman with CHF exacerbation. Along with examining the patient and checking her chart for what medications she was on, I looked around the room. There were hinged windows that were all open to the warm, humid air outside. The fans were on. The large room had six patient beds, all of which were filled with women of varying ailments. There was essentially no privacy in the rooms. The simple beds had an IV pole and well used but relatively clean fitted sheets with eccentric patterns.
My senior mentioned that there was a febrile patient in the emergency department that showed up with vague symptoms whose blood work should be back. I started thinking about a broad differential diagnosis. When the blood work came back there was neutropenia with elevated bilirubin and transaminase levels and schistocytes on the peripheral smear. I was just trying to process this information when I heard words like dengue, yellow fever, malaria, typhoid being thrown out.
Wait! I thought to myself. I vaguely tried to remember the pathophysiology of some of these names of diseases that were being thrown out.
“Did any cultures come back?” I asked, trying to make a contribution to the team.
“No, we can’t do cultures.”
“What do you mean?” I was dumbfounded. The administration had told the docs that cultures can’t be done at the lab. Everyone had his or her reasons as to why. Some felt it was to save costs, others that there is a shortage in supplies. No one knew why, but blood cultures were out of the picture. This was frustrating for our next patient, a community-acquired pneumonia that was getting sicker, despite the antibiotic coverage becoming broader. I’ve never been told I can’t order cultures before, and it was at that point I realized that this elective was going to be challenging.
Rounds were eventually over for my team and I looked at my phone to see messages from some of the other Canadian medicine resident physicians.
Anyone done rounds?
Me! I answered
We’re outside the emergency entrance
I soon learned that after rounds we would meet daily for our coconut water. It was 200 Guyanese dollars, or the equivalent to 1 USD.
We would grab a quick lunch from the local “pharmacy” or modern French café near the hospital…but the best food I had was cook-up being sold from the back of a van parked outside of the hospital. We would gather and talk about what we saw during rounds and the differences between the Canadian system and Guyanese system. I made sure to read on some of the infectious diseases that I’ve never seen in Canada.
The systems were so different! There were no blood cultures available. Some tests we wouldn’t even think twice about ordering in Canada were too expensive for the patients to order here. Physical exam skills were heavily relied on. A CT for a patient was at times too expensive to have done. An angiogram was something that only the wealthy could afford. I never verified if this was indeed true, but it was told to us that the cost of one angiogram was near 200,000 Guyanese dollars. Some of the resident physicians mentioned that during call they saw patients that were in critical condition, intubated but resources didn’t allow for ICU admission and adequate ventilation. One of the resident physicians mentioned her frustration running a code with no help and having a patient pass away in front of her eyes. It was hard. We managed though, with the help of frequent Dairy Queen visits, venting sessions, listening to calypso and Soca music, morning runs, and of course, coconut water. All 5 of us ended up creating such a strong bond. We got to know each other very well after living in a house for 4 weeks together (including each other’s bowel patterns). It was very clear though, that having the support of one another was what helped us cope with the stressful aspects of the rotation.
After talking to the resident physicians and fellows we discovered that about 10 years ago the residency program barely even existed. The two computers in the room were fairly new. The clerks mainly were trained in Cuba previously, but recent medical schools had popped up in the country. Many of the resident physicians attributed a lot of the positive changes in the medical training of Guyanese doctors an initiative taken on by internal medicine doctors through the University of Calgary. Some of the residents had even been to Calgary for CCU or ICU experiences.
I was also fortunate enough to spend 2 weeks with the Family Medicine resident physicians at various clinics in Georgetown and the surrounding area. I even gave a presentation on smoking cessation during a session of academic half days. The Family Medicine residency program was being run in conjunction with the University of Ottawa. I later learned that the graduating class of Family Medicine resident physicians in November is going to be the first graduating class of Family Medicine doctors in the country! There were no Family Medicine doctors in Guyana prior to this. I was so impressed at the outpatient clinics, especially the HIV clinics. Multiple medications and office visits in public health clinics were funded by the Guyanese government, including HIV antiviral medications.
I remember seeing a sticker on the clinic door that said, “Keep this door open—stop the spread of TB”. There were always doors and windows open in the clinic. This prompted me to do some reading. Apparently the literature suggests that a modest decrease in the spread of TB was noted in clinics that had natural ventilation with open doors and windows. Here I was, learning about how the developing world deals with TB and it put so much into perspective. We are so fortunate in Canada to have the resources we do.
The medical knowledge and appreciation I gained during my elective in Guyana were second to none. It was the people, however, that left a lasting impression. We were lucky enough to spend some of our free time with the resident physicians and explore the beautiful country. Our first big holiday we were lucky enough to experience was Mashramani, Guyana’s 48th Republic Day. We wore colourful masks and held Guyanese flags as we watched the parade go by. Phagwah, or Holi, an Indian holiday celebrated by throwing coloured powders and liquids at one another, was another fun event! During this time Steven was in Baramita, holding an outreach clinic with many Amerindian people.
We were able to boat across the Mazaruni River, stay at the Aruwai resort and climb the waterfall in Bartica. We also saw the largest single drop waterfall, Kaieteur, and gained a new appreciation for Guyana’s untouched rainforest. Time spent with the Guyanese resident physicians, however, was one of my most memorable moments! I still text some of the resident physicians from time to time and I truly feel that I have created professional and personal relationships that are going to last a lifetime. This elective has not only reinforced my interest in international medicine, but has helped me become a better doctor by pushing me to be more resourceful. I would definitely recommend an international elective my colleagues. It has left a permanent impact on me, and I am forever grateful for this opportunity.
Dr. Beauty Sandhu is in Family Medicine at the University of Calgary.