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Date: May 14 '01 1. Description of the orthopedics complex (Dr. Valdes). 2. Presentation of a trauma patient case by an orthopedic staff physician Ortop is a complex including an orthopedic hospital, hotel, rehabilitation, sport and dance treatment, training facilities, orthopedic appliance and tissue bank production, research, conference center, and "health tourism". It is a self-financing (excl. MD/staff salaries paid by state) through fees charged foreign and resident alien clients who may subscribe to certain services on a per month basis, or pay for care. The hospital receives patients by self or physician referral, through outpatient clinics or direct admission. There are 22 O.R. suites in which 25-30 cases/day are done. There is a "solidarity ward" accessible to patients from third world countries based on need, and 2 other wards available to foreign pts. on a pay basis. Analgesics are in particularly limited supply. Nuclide scanning is available; there was no mention of CT or MR. The length of stay is inclusive of complete rehabilitation, with follow-up conducted through the health ministry at municipal levels. There are orthopedic MD's available at provincial and municipal polyclinic levels. Additional specialty MD's are on staff for ICU, medical consultations, etc. Communication for other specialty care needs is through consultation or transfer of the patient to another specialty facility. Most fixation devices, prostheses and appliances are manufactured on site. 4:00 - 5:45 National Health Service: organization/statistics Dr. Francisco Gonzales Hencio Dr. Marielena Sanchez Pino (panchito@infomed.sld.cu) Lecture/discussion at Hotel Organizational characteristics: All (except military - separate system) Under Ministry of Health National | Provincial | Municipal | local health area Priorities: (National)
58 MD/10,000 population (1:172 population) 30,000 General practitioners Nurses 78/10,000 (1:128 population) Life expectancy 76 yrs. Infant mortality 6.4 New birth rate: growth 0.5% /annual 9% of budget to health = 153 Cuban Pesos/capita/yr. Leading death causes:
Garbed decrease in death rates due to infectious agents Prevalence: HTN 33%; Smoking 47% Among Adolescents: Death - 1) Accident, 2) Cancer, 3) Suicide Teen Pregnancy increasing to 13% 99+% of deliveries in hospitals 100% hospital autopsy rate For chronic diseases GP issues prescription card for pharmacy to allow pt. access to medicines. Nosocomial and resistant organisms low (? Due to limited antibiotics.) 99% of population vaccinated against common diseases. May-14 Habana 6:00 pm - 8:30 pm (Lecture at hotel) Dr. Rodolfo Stusser; Clinical Research Ctr. - Stusser@Informed.SLU.CU Exposition of his analysis of developments in Cuban medicine and science in 4 historical segments dating from early Spanish yrs., yrs. of US influence, post revolution (1959); since 1990 characterized by the social, political, and economic factors that dominated each period. In 1900, life expectancy was 33 yrs, and the leading cause of death was infectious diseases. By 1959 there was a fairly well developed social infrastructure , but compared to Latin America, huge economic disparity. By 1959life expectancy. was 63 yrs. and the leading death cause was cardiovascular. Shortly after 1959 Revolution, nearly half of the doctors left Cuba. As Cuban reliance on Soviet bloc grew, features of Soviet model of care were implemented. 1975 was just 5-year plan in Technical and Research fields. The policlinic model in Cuba is similar to Russia prior to dissolution of Soviet Union. When the Soviet Union collapsed, Cuba quickly lost huge amounts of infrastructure and subsidy. There were severe shortages of food, fuel, medicines, etc. severely affected health system. Cuban doctors have Internet access via Infomed but is fairly limited - 50-60 web pages available - server access determined by the state. Limited availability of computers. (Drs. Gonzales, Ladaya, Silva) 15 May - Habana Hospital Docende Miguel Enriquez University level "secondary" general hospital; trains med students: technical and nursing staff etc. One of two emergency (trauma) Havana hospitals. Stepped care: Acute cardiac admissions: 1) Emergency Ward 2) ICU (mixed case type) 3) Intermediable care 4) Cardiology ward (24 beds) Cath intervention including surgery referred to tertiary centers: A total of 4 in country - Havana (2), Santa. Clara (1), Santiago de Cuba (1). This Hospital treated approximately 250 MI's in 2000; 50% got IV Streptokinase (not tPA) All MI patients-(not transferred) -In Hosp. mortality =17.8% Uncomplicated AMI-Ave. Length of Stay= 11 days, includes cardiac rehab. Follow up either at hospital in policlinic. Stress test by 2 weeks. Every polyclinic (municipal) has an emergency team for acute care. Access for acute coronary care can be to any level facility. There is an extensive thorough pt. record system that identifies pt. outcomes and can detect areas with problems. Ex: If a municipality with high mortality is identified, this leads to efforts to improve performance, including patient and community education. Tertiary referrals: tertiary center sends out ambulance with M.D. Low rate of PTCS/CAB after MI: Risk stratification post MI by stress testing. Typical MD work week (cardiol): M-Sat 8-4:30 4 weeks vac/yr. Primary limitations: outdated or hard to repair equipment; (e.g., their treadmill is broken for the last 5 months); pharmaceuticals, not all hospitals caring for Cardiac patients have access to CPK or Troponin assays. They also need defibrillators 16 May , 10-11.30 AM Instituto de Cardiologia y Cirugia Cardiovascular Prof. D. Alberto Hernandez Canero, director Calle 17 N. 702 Vedado, Habana4, Cuba Inscard@infomed.sld.cu 1 of 2 cardio tertiary institutes in Havana (1966) Approximately 100 CV surgeons, cardiologists, etc. Research, Educ., Intervention and Clinical Cardiology, CV surgery. Approximately 300 open hearts/yr., 1/3 valves (from Brazil). Previously, open Heart Surgery volume was nearly 600 - cut drastically during 90's, now rising. 4 "teams": 1) Adult Cardiac Surgery 2) Ischemia (coronary syndromes): cor. Care, lytics, cath, PTCA /stent, echo, stress, (800 cath; 200 PTCA, 70% stented.) 3) EP - 600 pacer implants, single and dual and biventricular; 15 ICD's; approximately 200 ablations. 4) Preventive cardiology New Aloka 2D echo, no TEE yet Nuclear: Planar, soon SPECT. Other center has MRI. CPK MB yes, Troponin- no. Needs: PTCA supplies (Currently, they re-use PTCA Caths up to 4 times) EP catheters Drugs Santa Clara 16 May, Wed. 4-6:30; Met with surgeon, cardiologist, anesthenologist, nurse, anesthesiologist at hotel National/Regional Center for Cardiac Has med school, residents/fellows. Started Heart Center 1987. Organized as an integrated team - cardiology, CV surgery, anesthesia, nursing. Serve 2-million population area 3000 open hearts since 1987 - volume rising but limited by equipment and funds. Active exchange programs (faculty, fellows) with foreign countries especially Europe and Canada. Facilities:
CV surgeons (6 yrs.) must spend 1 yr. in Cardiology. 3 level board exam for all specialties. New specialty (2000) in Critical Care. Nursing: Bachelors level incl. 2 years. Cardiac First ICU's in Cuba 1972 in Santa Clara 1973 Weekly joint meeting to plan workweek, review and prioritize cases. Electives fairly long wait list. Urgent/emergent-- no delay. Focus on getting pts. home earlier to GP and municipal polyclinic. Surgical standby for PTCA, few same session PTCA. Off pump CAB new (15 cases) - Approx. length of stay for CABG = 8-10 day Cath lab soon to be replaced by Digital system Needs: OR monitoring upgrades - IV drugs; Antiarrhythmics Supplies 18 May, Fri., Varadero Overall Impressions There were several consistent themes from all the physicians, and in the facilities we visited. They all emphasized their agreement with the philosophy of how Medical especially Cardiology care is organized in Cuba, and also that their limiting factors are primarily shortages of pharmaceuticals, supplies, and up to date equipment. It appears that they perform very well given the resource limitations, for example 2% mortality for open-heart cases in Sta. Clara. The physical plants, in comparison to what we are accustomed to, are dated and often in need of repair. Laboratory facilities are extremely basic. The economic crisis of the early-mid 90's was a severe blow from which they are slowly recovering. They expressed frustration, but not necessarily resentment, with the U.S. embargo, because of its impact on the people. There seems to be a strong communal spirit among the physicians. Care is delivered with the means available and at what is judged to be the most appropriate site and facility. The public health is of primary concern. While by our standards incomes for physicians in Cuba are very low, they are at the upper range of Cuban incomes. They expressed no rancor about this, and often described the economic and other support provided by the state, e.g. free education, free health care, state subsidized food program (ration system). However, it was clear that additional sources of income are usually necessary, e.g., several family members working, funds sent for foreign relatives (esp. U.S.), etc. Overall there was a sense of professional dedication and teamwork that transcended the economic and political realities. |
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