The Pharmaceutical Journal
Vol 277 No 7483 p740-742
22/29 December 2007

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Getting clinical in the Cayman Islands

In 2000, Christina Short and her husband crated up their possessions, rented out their home and moved to Grand Cayman, where she took up the post of clinical pharmacist for the government health service, joining a team of 11 pharmacists, five technicians and two assistants. In this article, she describes working in the “Jewel of the Caribbean”

Christmas miscellany 2007 index

Best known as an off-shore tax haven, the three-island archipelago of the Cayman Islands is located in the western Caribbean about 150 miles south of Cuba, 460 miles south of Miami, Florida, and 167 miles north west of Jamaica.

Grand Cayman, the largest of the three islands, has an area of about 76 square miles and is approximately 22 miles long with an average width of four miles. The island is low-lying, with the highest point, “The Mountain” about 60 feet above sea level.

Situated about 89 miles northeast of Grand Cayman, Cayman Brac is about 12 miles long, with an average width of 1.25 miles, and has an area of about 15 square miles.

The Bluff, a massive central limestone outcrop for which the island is named (brac being Gaelic for bluff), rises steadily along the length of the island up to 140ft. at the eastern end. Little Cayman, sited five miles west of Cayman Brac, is approximately 10 miles long with an average width of just over a mile.

A 2005 estimate of land use determined that the Cayman Islands had 3.85 per cent arable land and no permanent crops, with about 90 per cent of the islands’ food and consumer goods being imported. There is no direct taxation.

The government’s primary source of income is indirect taxation: a duty of 20 per cent is levied against goods imported into the islands. Few goods are exempt; notable examples include books, cameras and baby milk. A flat licensing fee is levied on financial institutions that operate in the islands and a small fee is charged to each tourist arriving on the islands.

Tourism accounts for 70–75 per cent of the annual gross domestic product and 75 per cent of foreign currency earnings of the Cayman Islands. The industry is aimed at the luxury and diving markets, catering mainly to visitors from North America. Of the one million plus tourists who visit the islands annually (around half from the US), 99 per cent stay on Grand Cayman. The capital George Town on Grand Cayman also serves as a major cruise ship port, which brings in 4,000–22,000 tourists a day.

Grand Cayman’s major attraction is Seven Mile Beach on which most of the island’s hotels and resorts are located. Other tourist draws include the black limestone spires of Hell, a turtle farm, the Queen Elizabeth Botanical Garden and Pedro Castle. There are several snorkelling locations where tourists can swim with stingrays.

The Cayman Islands have a tropical marine climate, the temperature seldom goes lower than 21C or higher than 32C. The average is 26C in the winter and about 30C in the summer. The average annual humidity is 77 per cent. Rainfall varies over the islands and seasonally, but in George Town the average monthly figure is six inches.

A major natural hazard is the tropical cyclones that form during the Atlantic hurricane season from June to November. On 11 and 12 September 2004, 95 per cent of the buildings on Grand Cayman were damaged by a category five hurricane (Ivan). Power, water and communications were all disrupted. The magnetic resonance imaging scanner at the hospital was also destroyed. Ivan was the worst hurricane to hit the islands in 86 years.

The islands are also located on the plate boundary between the west moving North American and eastward travelling Caribbean tectonic plates. Minor tremors are recorded but in December 2004, a quake of 6.8 magnitude rocked Grand Cayman. Short in duration, the earthquake opened some small sinkholes but otherwise did no damage.

The latest population estimate of the Cayman Islands as of April 2006 is 57,800, representing a mix of over 100 nationalities, about 50 per cent of whom are of Caymanian descent. Most people live on Grand Cayman. About 2,000 people live on Cayman Brac and Little Cayman has around 200 permanent residents.

Health care

Comprehensive medical services are available on the islands. Health insurance, handled by private insurers and a government-run company Cayman Islands Health Insurance Company, is mandatory. There is no universal health coverage as in the UK and health care and medicines are costly.

There are two hospitals in on Grand Cayman, the Cayman Islands Hospital (referred to locally as George Town Hospital), run by the Health Services Authority and the smaller, private Chrissie Tomlinson Memorial Hospital. Cayman Islands Hospital is a modern two story, 124-bed hospital, and the principal health care facility in the country. It offers accident and emergency services, full maternity services, daily general practice surgeries, haemodialysis, operating theatres, physiotherapy, a pharmacy, a central sterilisation unit, and laboratory services, including a state-of-the-art forensic unit.

The hospital’s affiliation with Baptist Hospital of Miami caters for patients requiring advanced care or treatment and with contracts with hospitals in Florida and the West Indies addressing long-term care. Medical evacuation services to Miami are available, when necessary a Lear Jet B-20 is available for transportation to US facilities at two hours notice.

The four district health centres in Grand Cayman are staffed by a wide range of health and social care professionals and function as extensions of the hospital outpatient department, offering community-based preventive and curative services.

The 18-bed Faith Hospital on Cayman Brac serves the residents of Cayman Brac and Little Cayman, providing primary, secondary, and emergency care. Faith Hospital physicians cover general medicine, surgery, anaesthetics, and obstetrics and gynaecology. Regular visits by specialist physicians from the Cayman Islands Hospital provide paediatric, orthopaedic, ophthalmology, urology, mental health, nutrition and ear, nose and throat services.

On Little Cayman a purpose-built health care facility has a waiting area, a triage area, treatment room, and offices for weekly physician’s and dentist visits. A registered nurse conducts clinics on weekdays, makes home visits and provides pre-hospital care services in association with a paramedic.

There are eight community pharmacies on Grand Cayman with two open for 12 hours a day and many open on Sundays. Most take a more American retail approach, resembling a “drugstore” and selling items more analogous to a tourist shop or newsagent (see image right).

Drugs and other medical equipment are not manufactured in Cayman. Legislation provides controls for the importation and dispensing of drugs. Approval of the Health Practitioners’ Board is required for the use of drugs and medical equipment not produced in the US or UK.

Pioneering the clinical pharmacist role

The establishment of a clinical pharmacy service had the support of many health care professionals within the Health Services Department. Development of the service was made in consultation with these people and, to this end, a needs assessment was undertaken. All respondents indicated a requirement for medicines information, both reactive and proactive.

All groups also identified issues relating to the functioning of the Drug and Therapeutics Committee as a priority, with medical staff recognising the need for the production of critical independent reviews of individual and therapeutic groups of drugs. All staff groups requested dissemination of DTC decisions.

Key roles of the clinical pharmacist identified by the needs assessment included providing medicines information, and intervention monitoring.

Medicines information service A medicines information service was established and provided to all health care professionals and the general public. In keeping with international standards, all queries were recorded and indexed. Most questions could be answered with either a telephone call or brief written report.

New to me was giving responses for use in legal cases (eg, inquests and medical competency investigations) and, for these, more work in analysis, interpretation and reporting of the information was required.

Intervention monitoring Maintenance of an intervention log demonstrated the early recognition of the clinical pharmacist as an informed member of the team, with up to 91 per cent of interventions resulting from a proactive approach to the clinical pharmacist for information by other health care professionals and the public.

Drug and Therapeutics Committee During my tenure as clinical pharmacist the effectiveness and productivity of the Drug and Therapeutics Committee increased markedly. Experienced leadership, revised membership to include designated specialty representatives and the provision of supporting evidence-based briefing papers facilitated informed discussion and debate in meetings.

Prompt circulation of information relating to decisions made by the committee in the form of a newsletter sent with and corroborating the minutes gave more information on key decisions. The committee also became actively involved in the production of evidence-based medicine guidelines.

Local peculiarities

There are no endemic tropical diseases, and the islands are non-malarial. However, some medical problems are caused by diving or eating seafood.

Ciguatera poisoning Ciguatera fish poisoning occurs as a result of the consumption of semitropical bottom-feeding fish that dine on plants or smaller fish, which have accumulated ciguatoxins from microscopic dinoflagellates, such as Gambierdiscus toxicus. The larger the fish, the greater the toxicity. The ciguatoxin-carrying fish most commonly ingested include the jack, barracuda, grouper and snapper.

Symptoms, which usually begin 15 to 30 minutes after eating a contaminated fish, include abdominal pain, nausea, vomiting, diarrhoea, tongue and throat numbness, tooth pain, difficulty walking, blurred vision, skin rash, itching, tearing of the eyes, weakness, twitching muscles, inco-ordination, difficulty sleeping and occasional difficulty in breathing.

A classic sign of ciguatera intoxication is the reversal of hot and cold sensations. Unfortunately, many of the debilitating symptoms may persist in varying severity for weeks to months. Treatment is, in the absence of a specific antidote, for the most part symptomatic. Intravenous mannitol 1g/kg effects a dramatic reversal of neuromuscular symptoms with a slower resolution of gastrointestinal upset and abnormal heart rhythms.

Vibrio infections The gram-negative bacilli of the genus Vibrio are indigenous to the marine environment and are natural flora of shellfish. Thriving in warmer temperatures Vibrio species cause infections in humans ranging from otitis to gastroenteritis, septicaemia and meningitis and should be suspected in patients presenting with fever, shock, wound infections or pneumonia where there is a recent history of immersion in salt water.

Among the most common injuries from marine life seen in accident and emergency departments are coral scrapes. The surface of coral is covered by soft living material, colonised with Vibrio species. This is easily torn from the rigid structure underneath and deposited into a scrape or cut.

Treatment is with gentamicin or a fluoroquinolone. An audit carried out in conjunction with the Caribbean Epidemiology Centre found this to account for the high incidence of the use of single 400mg IV doses of ciprofloxacin in A&E, based on a mis-understanding around oral absorption and tissue distribution, coupled with a local belief in the greater benefit of an injection over a tablet.

Decompression sickness First described in 1841, decompression sickness (DCS) is a disorder resulting from reduction of surrounding pressure, as in ascent from a dive, and caused by the formation of bubbles from dissolved gas in blood or tissues. Called “the bends” by early investigators, DCS is usually characterised by dull limb pain or exceedingly variable neurological symptoms (ranging from mild parathesia to major cerebral problems), or both.

Recompression with the objective of compressing the bubbles to asymptomatic size, redissolving them and restoring adequate oxygen to the affected tissues, is imperative and must be accomplished as soon as possible to avoid serious and lasting injury.

During recompression adequate fluid intake and monitoring is important, with 0.9 per cent sodium chloride the fluid of choice if IV therapy is required. Bladder paralysis and the need for catheterisation are possibilities that should be considered.

Dexamethasone may be indicated for reducing central nervous system swelling and controlling oedema, especially where the response to recompression is inadequate or delayed. Sedatives and narcotics should be avoided or, when urgently needed, used in minimum effective doses due to the potential to obscure symptoms and cause respiratory depression.

The Cayman Island Hospital has a two-person, double-lock recompression chamber staffed by a 24-hour on-call team of trained operators and supervised by a physician experienced in hyperbaric medicine for treating diving-related accidents.

Carpe diem

I would encourage any pharmacist or pharmacy technician, given the opportunity, to try working in another country. Pharmacists and pharmacy technicians registered in the UK are eligible for registration with the Cayman Islands Health Practitioners’ Board, via the Pharmacy Council.

Any vacancy must first be advertised and offered to suitably qualified Caymanians, of which there are few. There then is a preference for recruiting personnel of Caribbean origin, if this is unsuccessful the position is open to overseas candidates, most often these are from the US, Canada or the UK, all of whom must satisfy not only the prospective employer but also the Pharmacy Council, as to their ability and suitability.