Trinidad and Tobago Field Report: 2016

Published on October 6, 2016
Between 2005 and 2007, four new EM training programs began in Trinidad and Tobago, creating an explosion in new training and widespread coverage of qualified EM physicians.

The Caribbean is made up of a series of islands that follow a gentle, sloping trajectory from Miami to just east of Venezuela. Trinidad and Tobago is a twin island state (population 1.3 million) in the southernmost part of the Caribbean, and is the main and larger of the English-speaking islands in the Caribbean, which also include Jamaica (population 2.7 million), and Barbados (population 300,000).

The specialty of emergency medicine came to the Caribbean in 1990, in Barbados, and then Jamaica in 1996, with the start of the DM (Doctor of Medicine) training program. Prior to that, emergency departments were called “Casualty” and were staffed by non-specialized nurses along with interns and junior doctors who were supervised in various degrees, usually via telephone, by senior doctors with non-EM specialist training—typically surgeons and internal medicine specialists. Prehospital care was almost non-existent and mainly functioned as a transport system, where patients were picked up, given oxygen or CPR as required, and taken to the hospital as quickly as possible—literally scoop and run. There was also little exposure to life support courses such as Advanced Trauma Life Support (ATLS), Advanced Cardiac Life Support (ACLS) and even Basic Life Support (BLS).

Actual medical treatment did not really begin until the patient arrived at the hospital. Triage was inefficient, and life threatening emergency cases frequently waited long hours, sometimes with unfavorable outcomes. Contributing factors included limited availability of medical services, along with a large number of patients seeking medical care. This was in addition to an ineffective and unstructured primary care system, a lack of responsibility and ownership by patients with regard to their personal health, and the increasing popularity of alternative and herbal medicine, especially in the rural areas.

Trinidad and Tobago took a slight turn from the rest of the Caribbean on its course toward an EM training program. The four-year DM program began in Trinidad in 2005, led by Dr. Ian Sammy. An 18-month diploma program also began at this time, which was geared toward doctors working in peripheral and rural EDs, and rotating through primary centers, to give them some EM knowledge base to improve the standard of patient care before transfer to a tertiary center or before discharge. The diploma program was also meant to bridge the gap in EM training until there were enough DM graduates who might then consider working in these peripheral centres, a process that was estimated to take 5–10 years. A three-year MSc program was also added to cater to those senior doctors already in EDs, for whom it was not feasible to do the DM. Finally, the Diploma in Pediatric Emergency Medicine was started in 2007. This was available only for those already with DM or MRCPCH specialty degrees. (Three graduates of the pediatric EM program are now consultants in the Pediatric ED.) Thus, in one short space of time, four programs were started, each approaching EM training deficiencies at multiple levels.

Fast forward ten years. Ian Sammy is presently in the U.K. pursuing his PhD in EM (which is nearing completion), and the program coordinator is now Dr. Joanne F. Paul. Following the establishment of these four EM programs, training mushroomed and exploded after critical mass was achieved. Approximately 100 students have completed the Diploma; 16 have graduated from the DM program; and 33 are currently residents in the DM program. The Head of the ED at three out of four of the major hospitals in Trinidad and Tobago is a DM graduate, and the other is headed by an MSc graduate. The Diploma graduates are registrars in the tertiary hospitals, or heads of unit at the peripheral centers. Some have also gone on to do their DM in EM, while others are doing family medicine and other related specialties. What is especially distinctive, though, is that this explosion in training also created an environment where, separate from the training within the program, the DM graduates teach and mentor the current DM residents in each tertiary hospital. In turn, DM residents teach and mentor the current Diploma students. The result is that, in Trinidad and Tobago, the EM revolution has not devoured its children but, instead, these children have grown up and are taking care of each other.

Eventually the specialty will be saturated and there will be an EM specialist in all tertiary, secondary, and peripheral rural centers. This may be another ten years away. At present, though, the result of seeding the initial ‘Casualty Departments’ with concurrent and multiple programs is vastly improved standards of care for patients in a middle- to high-income developing country, at the end of the line of the Caribbean Islands.

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