Tuesday, February 23, 2016

Pathology in Trinidad

Melanie Johncilla, MD
Fellow in BWH Pathology

I left Trinidad when I was 18 years old.  I’ve never worked in the country and since I left it’s always been a place I equate with vacation, beaches, sleeping in late and having home-cooked food.  Given my experience working with folks in other “lower resource” settings like Rwanda and Haiti, I began investigating Trinidad as one of those ‘settings’.  After a small needs based assessment, I decided to do a project that would bridge very evident knowledge and practice gaps in the country.

Showing Dr. Greaves and his house officer Kavita the
 telepathology system (the iphone is attached to the camera and 
I'm uploading it on to Ipath for outside consultation).

And here I am.  In a room in San Juan, Trinidad with blue walls and a rectangular window waiting for my turn with the one microscope (I gave it to ‘my house officer’ who is previewing some unknowns I brought from the Brigham for a teaching session later this week).  The microscope has no light filter, no 2 or 20x objective and - I’ve mentioned this already - there’s only one of them.  I need it to attach my one (donated) iphone so I can then project slide images onto my laptop and begin teaching.  It’s different from having my pick of the litter at the Brigham (objectives, filters, microscopes..) but oddly enough I love it.  I know I only have one microscope and I know that my old high school friends are leaving work early to go the bar or a carnival fete (it’s what Trinidadians call a party).  But I don’t think I’ve ever been this excited about a project before.  
The first attempt at immunohistochemistry I asked for:
Reynard and Sherwin, our lab assistants.

I could spend time on this blog regaling readers with tales of mistaken diagnoses, maltreatment based on diagnoses from the four (total!) pathologists here (the best of whom completed their training in the early 90’s and didn’t ‘believe’ in immunohistochemistry until a few years ago).  I could detail the story of  the one pathologist who diagnosed a 17cm mass in a decompensating 70 y/o man with the words “cells, staining for CD20, CD5 and CD3, clinical correlation is needed”.  But I, embarrassingly, expected that practice type.  What I did not expect is my colleague, Wesley Greaves, MD, FCAP who maintains the integrity, professionalism and knowledge base he built while at MD Anderson and Brown and then brought that essence to his practice in Trinidad.  Though severely restricted in terms of resources, his practice of pathology rivals that of the Brigham.  His staff is beyond motivated, beyond innovative and frankly, had they been based in the US with grants to apply for, courses to take, they would be among the best, if not the best.  Resource restriction is quite a thing.

The entire experience is not without its negatives (on my part).  As I sat in my one hour traffic filled commute, I momentarily lapsed into a  line of thinking probably fueled by the frustration of just getting to the lab.  Here I am, I thought, a fellow in Boston with arguably unlimited access to resources and connections and here I go, to a lab with three immunostains and one microscope, what am I doing here?  The gap is wide and after sitting here for four days and recovering from my commute, I feel my own privilege and my own entitlement and that’s also quite a thing.

The grossing station at the lab.
Other than this practice, if I could sum up Trinidad in one word, it would be hot.  Soca (calypso music with a faster beat) is playing on a laptop on our assistant’s desk as he comments on who will win the competitions that are coming up (Carnival is in two weeks and besides heavy dieting, Trinidadians turn into music critics and compare this year’s crop of costumes, ‘fetes’ and songs with the last years', somehow the last years' is always better).  Even though my accent is as strong as it’s ever been, my co-workers here still feel the need to educate me on things ‘Trini’.  I don’t know any of the new slang and tend to use the American term/pronunciation for a few things well rather than the more traditional British.  

I needed a few minutes to write this, but cases, patients and house officers await.  The practice of Pathology is different here.  It’s dynamic, engaging and developing.  And, four days in, I love it.

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