The Tribune

EDITOR, The Tribune.

I read with interest the editorial written by Ms. Eileen Dupuch Carron, “Foundation started for paediatric health care”, on Monday January 9th, 2017.

I would like to state emphatically that my heartfelt sympathies go out to the Carron family during this time of family illness; and I hope that Aidan will quickly recover and have a normal and healthy life. I have also had near death experiences with a family member and truly empathise with the Carron family.

I would also like to say that I admire and respect Mrs Carron for her firm stance on all things ethical and the adherence of The Tribune to similar standards.

There are many issues with the article and hopefully medical consultation was sought prior to Mrs Carron writing the editorial.

First, the epidemiology of Hemophagocytic Lymphohistiocytosis (HLH):

1) A review of the medical literature would show that HLH was described as early as 1939 (77 years ago) in J Blood Med. 2014; 5: 69–86. Hemophagocytic lymphohistiocytosis: review of etiologies and management Melissa R George).

2) The incidence of HLH is really unknown and under-diagnosed in all corners of the globe. The incidence of HLH has been estimated to range from 1 in 50,0000 births to 1.2 per million persons worldwide.

3) Please note that the above article also states that the long-term survival rate for HLH is less than 4 per cent.

4) The incidence of HLH seems to be higher in Asians. A literature review of one study of over 2000 HLH patients revealed that over 50 per cent were Asian

5) Most diagnoses are made at less than three months of age.

6) Due to the rarity of the disease it is under-diagnosed worldwide.

In her editorial, Mrs Carron stated that due to our nation’s small size, “…many of our doctors do not have the luxury of going off on refresher courses to keep them up to date or to learn what mysteries foreign doctors are uncovering…”. Mrs Carron should note that it is a requirement for medical licensure in the Bahamas to have an annual minimum of twenty Continuing Medical Education units (CME’s). This requirement is far and above many Western Industrialised Nations. In addition, most consultant physicians trained in the last twenty years have to study and take written tests to maintain their memberships in professional organizations such as The American College of Surgeons and The American Society of Anesthesiologists, to name a few. In addition, many of our consultant physicians (admittedly not all) do CME training far and above the minimal requirement to remain on the cutting-edge of medicine: training in ultrasound diagnostics, for example, that will enable faster, more definitive diagnoses to be made at the point of care.

Despite our efforts as a profession to maintain the highest standards of training and education, Bahamian doctors must continually fight against the layperson’s assumption that Florida healthcare systems are some sort of panacea. Just because Florida institutions are abroad does not equate with them being better. Not every Florida institution equates to the quality of top-notch institutions such as the Cleveland Clinic (which by the way has trained more than a few of our physicians.)

We appreciate Mrs Carron’s efforts to emphasise that “At no time [has The Tribune] inferred that our Bahamian doctors are unqualified.” Unfortunately, however, that is not the message that comes across. To insinuate that Bahamian consultant physicians may not be up to scratch is truly insulting. In addition, for a physician in Florida to second-guess a physician in Nassau is truly unethical. Barring gross malfeasance, such judgments are difficult and dangerous to make. Making comments such as “Aidan should have been admitted to hospital on the day his mother was agitating…”, “the evidence all pointed to an overload of vaccines..”, etc. in hindsight is something that a physician should never do. If that/those physicians had made similar comments about a U.S. based physician(s) they would have immediately been either taken to court for libel, had their privileges suspended or worse. Perhaps they feel safer making such statements about foreign physicians – but that doesn’t make it okay.

We have had many Bahamians go to Florida Hospitals for treatment. More than a few have returned home to receive the proper medical care needed. Others have returned home “in a box”.

To make a point with regards to training and qualifications, even a small sample of our consultant level physicians (including paediatricians) indicate training received at some of the most prestigious medical institutions in the United States, including: the University of Miami, University of Michigan (Ann Arbor), Johns Hopkins University, Temple University, and New York University, to name a few.

In emergency situations, treatment often appears frankly horrifying to the layperson, especially when distraught at the condition of a loved one. Referring to the tech assigned to pull a blood sample, the article stated that “Obviously, with no vein available, she dug down too far in search of a vein, leaving a large blood filled haematoma that took up most of the baby’s forearm”. With regards to the attempt to take a blood sample, this event would not be uncommon given the situation at any hospital – anywhere in the world. In fact, readers need to understand that there are many places in the world where the outcome of that incident would have been much worse.

Despite what was admittedly a highly charged, emotional situation, let us take a step back and examine the criteria with which the Bahamian doctors were faced:

1) The child was most likely dehydrated after having a fever and vomiting.

2) The child was most likely not of Asian descent.

3) The parents were obviously distraught, as well they should have been.

4) The child has a condition that is under-diagnosed worldwide and is still not fully understood.

5) The incidence of the disease has been estimated to be anywhere between 1 in 50,000 to 1.2 in a million.

6) The child was seven months old and the diagnosis of HLH is usually made in infants less than three months old.

By Mrs Carron’s own admission, the doctors at Miami Children’s Hospital were puzzled by Aidan’s condition. It was not until the next day that they felt able to diagnose his condition – and still required the results of tests, sent from Cincinnati weeks later, for confirmation.

Has anyone watched the film “Sully”, the movie documenting arguably the greatest landing in commercial aircraft history? The group making decisions in hindsight was terribly wrong and almost sullied (no pun intended) Captain Sullivan’s pristine career. A similar situation seems to be happening here where family members and foreign physicians who had the benefit of excellent communication from top notch Bahamian physicians, proper laboratory studies and most of all – the luxury of TIME - are now passing judgment in hindsight.

Mrs Carron states in the final paragraph of the article that “we decided that the only way to make certain that it never happens again to another child is to set up a foundation that will open the doors for our practitioners to benefit from a wider vista in medicine”. Again, I applaud this effort and wish the Foundation every success in attaining their goal.

However, what Mrs Carron is doing is looking at healthcare in a vacuum. I don’t know if Mrs Carron realises it but the primary reason that the outcome was successful was due to the family’s financial resources plus the expertise and vigilance of our Bahamian physicians. Had Aidan been without the family’s financial and other resources the outcome might have been very different.

This now begs the question “How do we ensure exceptional healthcare for all of our Bahamian citizens and residents and not just children?” Our public health system is truly in a state of disarray and as with any solution there must be a short, medium and long-term plan.

The discussion of National Health Insurance (NHI) has taken front stage recently and the question of how to fund it and have it remain sustainable and successful is an even bigger question. Bluntly speaking, NHI is a form of socialised medicine, which globally has not had a long-term history of success. In the short term, I believe an NHI scheme is a stopgap measure that can be successful if funded without putting the nation further in debt.

However in the medium and long terms, the problems of proper governance, crime, education, diversification of the economy, excessive taxation, reduction of government interference, etc. all have implications for the delivery of health care, and must be addressed.

Healthcare does not exist in a vacuum. The only way to achieve Universal Healthcare is to have Universal Employment consisting of meaningful, proper paying jobs, good governance and the rule of law.

The Tribune’s continued participation in the dialogue surrounding health care and NHI is important and valued, as all stakeholders strive to raise public awareness and invite discussion. I urge Mrs Carron and members of the media to visit the upcoming Medical Association of the Bahamas’ Annual Conference, where we will feature the Bahamian Diaspora of medical professionals. In addition, I would like to invite the recently formed Foundation to sponsor a speaker to discuss Paediatric Autoimmune Diseases at the upcoming and/or future Medical Association of the Bahamas Conferences.

Again, I extend heartfelt regards to the Carron Family and truly wish Aidan a rapid and full recovery.

Sy Coolidge

Pierre, M.D.

Dipomate of the American Board of Anesthesiolgy Fellowship, Adult & Pediatric Cardiothoracic Anesthesiology (New York University)

President, The Bahamas Medical Association