SPECIAL ARTICLE Surgery in Jamaica Peter Fletcher, FRCSEd; Archibald McDonald, DM(Surg), FRCSEd; Trevor McCartney, DM(Surg), FRCSEd; Reginald Carpenter, MA, MB BChir, FRCS amaica, at 4244 square miles (6830 km2) and with some 2.6 million inhabitants, is the larg- est and most populous country in the English-speaking Caribbean (Figure). The island is best known for its tourism industry, excellent rums, jerked pork, and, of course, reggae music. J HOSPITAL FACILITIES cated cardiothoracic and neurosurgery intensive care unit. Tertiary health care in Jamaica is pro- All the surgical specialties are repre- vided largely by the government. There are sented, and most surgical procedures are of- 23 government (public) hospitals and 10 fered. These include major bowel resec- private hospitals. Some of the public hos- tions, laparoscopic cholecystectomy, aortic pitals have small private wings attached. aneurysmectomy, radical cancer surgery, re- The government hospitals are clas- nal transplantation (mainly at the KPH sified as types A, B, C, and specialist. There now), joint replacement, liver resection, and are 3 type A hospitals: the University Hos- image-guided neurosurgery. It is the only pital of the West Indies (UHWI) and King- hospital in which open heart surgery is per- ston Public Hospital (KPH), located in formed and is 1 of 2 referral centers for neu- Kingston, and Cornwall Regional Hospi- rosurgery, the other being the KPH. tal, which is in Montego Bay. These are At the UHWI, there are some 4500 multidisciplinary hospitals that provide elective admissions each year to the vari- services for all medical specialties. They ous surgical specialties and 1100 trauma are fully supported by laboratory and ra- admissions. The number of operations diological departments and constitute the done by the various specialties is shown referral centers for the island. in the Table. All surgeons at the UHWI The UHWI is the premier teaching are full-time or associate academic staff of hospital in Jamaica and, arguably, in the The University of the West Indies. The at- English-speaking Caribbean. It com- tending staff includes 9 general sur- prises some 520 beds, with adult and neo- geons, 3 orthopedic surgeons, 2 urolo- natal intensive care units, renal dialysis, gists, 2 cardiothoracic surgeons, 2 and a division of emergency medicine with ophthalmologists, 1 neurosurgeon, 1 an accident and emergency unit. The ra- otorhinolaryngologist, 1 pediatric sur- diology division offers a full range of pro- geon, and 1 plastic surgeon. There are 4 cedures, including computed tomogra- qualified attendings in the division of phy and magnetic resonance imaging. emergency medicine, which is run by the The hospital initially provided service Department of Surgery, Radiology, Anes- for public patients only, but a 30-bed pri- thesia & Intensive Care. vate facility was added 12 years ago. Re- The Kingston Regional Hospitals cently, groundbreaking took place for comprise the KPH and 5 specialist facili- the addition of 2 operating rooms to the ties that provide multidisciplinary and spe- present 5-theater suite and for a dedi- cialist medical care for most Jamaican pa- From the Section of Surgery, Department of Surgery, Radiology, Anesthesia & tients. Intensive Care, The University of the West Indies (Drs Fletcher, McDonald, Located in downtown Kingston, the McCartney, and Carpenter) and Departments of Surgery, University Hospital of the 505-bed KPH provides medical services for West Indies (Drs Fletcher and McDonald), and Kingston Public Hospital adults in the specialties of surgery, anes- (Dr McCartney), Kingston, Jamaica. thesiology, medicine, radiology, and ra- (REPRINTED) ARCH SURG/ VOL 138, OCT 2003 WWW.ARCHSURG.COM 1150 ©2003 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 diotherapy. The accident and emergency care depart- ment sees approximately 60000 patients each year, of whom 20000 are referred for admission. There are 10000 elective admissions annually. The hospital is accredited for undergraduate and graduate surgical training. The specialist hospitals are the 250-bed Victoria Ju- Florida bilee women’s hospital (which provides services for ob- stetric and gynecological patients), 236-bed Busta- mante Hospital for Children, 100-bed National Chest Cuba Hospital (which initially served as a tuberculosis sani- tarium), 40-bed Hope Institute (an oncology hospital), and 70-bed Sir John Golding Rehabilitation Centre. The 400-bed Cornwall Regional Hospital is located in Montego Bay, the tourism capital of the island. There are 5 type B hospitals. These hospitals have the specialties of internal medicine, general surgery, ob- stetrics and gynecology, pediatric medicine, and anes- Jamaica thesiology. Most general surgical procedures are per- formed at these hospitals. However, the more complex cases are referred to the type A hospitals. There are 10 type C hospitals. These are headed by an attending gen- eral surgeon, who performs general surgical procedures and obstetrics and gynecology. The nature of the proce- Montego Bay dures varies depending on the anesthetic and nursing sup- Ocho Rios port available. Negril There are 10 private hospitals, 5 in Kingston, 3 in Montego Bay, 1 in the center of the island, and the other Kingston on the southwest coast. The bed capacities range from 20 to 50. All are supported by nearby laboratory and ra- diological facilities. SURGICAL DISEASE Jamaica Jamaica is the largest and most populous country in the English-speaking Surgical disease patterns in Jamaica are similar to those Caribbean. in North America. The common cancers (breast, col- orectal, and prostate) have a similar incidence. There is a high incidence of trauma, and trauma management com- Major Operations at the University Hospital of the West Indies prises 30% to 50% of public hospital practice. Diabetes mellitus is endemic, and the surgical complication of “dia- Service Elective Emergency Total betic foot” is common. Unfortunately, this frequently re- sults in amputation because of a combination of poor pa- General surgery 576 778 1354 tient compliance and inadequate resources. Urology 267 41 308 Orthopedics 109 680 789 Trauma patients are managed initially by general sur- Otorhinolaryngology 267 114 381 geons. At the KPH and UHWI, all the surgical specialties Cardiothoracic 264 66 330 are available 24 hours daily for consultations. Trained emer- Neurosurgery 135 120 255 gency medicine physicians are present in the emergency Pediatric surgery 191 58 249 departments of both these institutions. However, in the ru- Plastic surgery 82 12 94 ral hospitals, injured patients are seen initially by junior residents who are not in any training program. The prevalence of trauma in the urban areas has a negative effect on the ability of the service to offer elec- tive surgery to the population. At the KPH, 1 in 3 elec- GRADUATE SURGICAL TRAINING tive operations is canceled because of urgent trauma cases. In addition, the cost of delivering care to trauma pa- Regional undergraduate training in the arts and sci- tients comprises a substantial proportion of the health ences was formally begun in 1948 with the establish- budget. ment of the University College of the West Indies, un- At the KPH, trauma patients occupy 25% to 30% of der the aegis of the University of London, England. The the total bed complement at any one time. Twenty per- first Faculty of Medicine had an intake of 33 medical stu- cent of emergency admissions to the hospital daily are dents. In 1962, the University College of the West In- as a result of trauma. Most of these are orthopedic and dies became an independent entity, and the name was neurosurgical resulting from motor vehicle crashes. changed to the University of the West Indies. (REPRINTED) ARCH SURG/ VOL 138, OCT 2003 WWW.ARCHSURG.COM 1151 ©2003 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 Although the emphasis in the early years was on gency care services at the hospital, established the emer- medical undergraduate education, the medical faculty was gency medicine division, and initiated the training of emer- fully cognizant of the need to offer formal training for gency medicine physicians in Jamaica. The program has its graduates locally. Until the 1960s, graduate training 16 residents in training and has graduated 7 physicians in surgery for English-speaking Caribbean nationals con- with the doctor of medicine in emergency medicine de- sisted of local experience, followed by courses and ex- gree. aminations in the United Kingdom or enrollment in a An American College of Surgeons Advanced Trauma North American residency program. Although both op- Life Support program was started 2 years ago and has so tions produced qualified surgeons, neither was entirely far certified 106 physicians. There are plans to have all satisfactory. While those who became fellows of the Brit- emergency department physicians and surgical resi- ish Royal Colleges usually returned to practice in the re- dents certified through this program. gion, the British examinations were designed to select can- didates for training but not to assess their suitability for STAFFING specialist appointment. On the other hand, the North American programs, while providing a suitable exit- There are 96 general and specialty surgeons on the is- level qualification, also offered the opportunity for more land. Fifty-six work in the government hospitals, 22 at immediately rewarding practice appointments, with the the UHWI, and 18 solely in private practice. Forty- result that few returned to practice in the Caribbean. seven surgeons have the doctor of medicine in surgery In 1967, a formal proposal for instituting a gradu- degree, 76 have been awarded fellowship from the vari- ate surgical training course leading to the award of a higher ous Royal Colleges of Surgery in the United Kingdom, 4 degree by the University of the West Indies was submit- are fellows of the Royal College of Surgeons of Canada, ted to the board of the Faculty of Medicine.