Observations of life and medicine in modern Havana.
Visiting Cuba and trying to learn about life there is like peering through a shimmering window. You can’t get inside, but you get close, sounds are muffled, and you can barely see what is going on. And then for a while you can see everything clearly.
In November, 2016, I traveled to Cuba as part of a small delegation from Michigan State University’s College of Osteopathic Medicine, which was invited to participate in a national Cuban trauma conference. What I found was that Cuba is full of contradictions. You can feel the sensuous beauty of the graceful Malecón, the broad esplanade, and seawall that stretches for five miles from central Havana along the coast. The Malecón, with its crumbling grittiness, is home to fishermen and is a romantic refuge for young couples who have little private space at home. Cities are peppered with billboards and artistic graffiti of Fidel’s sayings. Many are inspirational and some are fading away more than a half-century after the revolution: “Mothers are the Foundation of Our Society,” ‘Take Care of our Mothers,” ‘The Duty of a Revolutionary is to Learn from Errors.” Today in Cuba, you can buy all the cigars you could afford; the cars, old and vintage, seemed to be in reasonable shape; and excellent restaurants have popped up.
As soon as you get through the custom and immigration exit doors at Jose Marti Airport in Havana, there is a dense crowd of excited faces, waiting for arriving friends and families. And then you have to run the gauntlet, a narrow path through the crowd that the crowd maintains so you and your luggage can get through to the taxi lane. The gauntlet slows every once in a while as people bounce and push in and exchange hearty hugs and kisses. Then the gauntlet stops, and there is agitated shouting between two men and a woman. Apparently, one man would not move out of the way enough to let a young woman through, and her waiting husband became incensed at such a lack of respect. A policeman comes, talks everybody down, and the stream continues through the gauntlet. While we’re all used to throngs waiting for airport arrivals at baggage claim exits, the scene and feeling in Havana is so different! Maybe it’s the isolation of Cuba, or the fierce independence of its people, but the exuberant welcome by so many of its citizens who seem to want to leave is unique. WELCOME TO HAVANA!
The conference theme was expanded beyond its original trauma focus to ‘Trauma and Emergency Care,’ as Havana’s trauma surgeons are realizing that emergency medicine could fit well into the health system and would allow the surgeons to eliminate their routine ED duty. Part of the conference was held at Calixto Garcia Hospital, Cuba’s national trauma center, with conference deliberations directed to the hospital director, the deputy minister of health, other hospital officials, and of course, the ED staff.
A special one day ‘Visa Habitacion’ was given by the Ministry of Public Health to enable a tour of the ED. This did not allow us to tour the entire hospital—only the ED. In general, the ED reminded me of typical city-county EDs of 30 years ago in places like Detroit Receiving Hospital or Charity Hospital in New Orleans: big but basic and worn-down. But there were some surprises.
The ED is large and simple with a census of about 2000 patients/day. Well, I think 2000 patients a day was a guess by the ED director, as there is no ED census. There is also no triage system.
How can that work, you ask? If an ill-looking patient comes through the ED doors, a staff or resident physician immediately materializes and gets the patient into resuscitation or the acute care areas. On the day of my ED visit, there were about 40 patients patiently sitting on benches waiting to be seen in one of two small urgent care cubicles called “boxes” by the ED staff. The “boxes” have a stretcher, BP cuff, stethoscope, and small desk for the doctor. I asked, “How do the patients know who is next?” I didn’t see any triage nurse, or log book, or any numbering system. The answer: The patients know exactly who is next to be seen. They make sure nobody cuts in. The same process holds true for the subspecialty clinics. So, the system is “self-triage” and sure seemed to work.
Later, I had reason to wonder if self-triage is part of the cultural and social fabric of Cuba. On Sunday, we noticed a large crowd of Cuban families patiently waiting to get served at a popular ice-cream store in Miramar. We hung around trying to figure out the rules of order, while more families kept coming in. We asked someone, “Who is last?” and someone answers, “Ustedes pertenecen alli.” and directed us to the end of the seemingly disordered crowd. That person knew exactly where we belonged. We saw the same type of self-triage among groups of people waiting to be served at food carts. No pushing, no arguing. Just knowing who was next and who wasn’t.
The acute care areas contain all the key materials—gases, monitors, pressure-based ventilators. And there was a nine-bed ED ICU staffed by two intensivists. While the specialty is officially termed “Emergency and Intensive Care,” intensivists see themselves as separate from emergency physicians. There are 2/day assigned to manage the ED ICU. They do not want to work in the ED because the ICU is their chosen environment. Patients are kept here while awaiting a critical care bed in the hospital the same as in the US. It could be hours; it could be two to three days.
The ED has its own well-equipped stat lab. However, the ED CT scan room was “under renovation,” and I was told they were waiting delivery of a new generation CT scanner. Until then, patients had to be moved to a scanner elsewhere in the hospital. The ED also has a moderately sized “General Urgent- Care-type waiting area” with benches. A hallway leads to subspecialty ED cubicles: ENT, ortho, surgery (for abdominal pain, lacerations or other injuries), and resuscitation.
Like EDs around the world, the ED staff is being crushed by an increasing volume of patients—even though the Cuban health system is free for all its citizens. Apparently, Cubans have the same desires for instant ED care that everyone in the world has. But there are insufficient ED physicians to manage the load. And running an efficient service is impossible when dependent upon rotating physicians and specialists from other departments.
The current system requires all surgeons to take their turns in working in the ED, 24/7. If staff surgeons go to the OR, residents take over care until the surgeon returns. Admission delays occur due to need for consultation. Nurses get burned out quickly and want to move to other departments. There are insufficient nurses anyway. Everybody looked tired.
Trauma surgeons are the de facto leaders of emergency care in Cuba. Dra Martha Larrea Fabra, the chief of trauma surgery, “Master of Urgencias Médicas” at Calixto Garcia Hospital, and former president of the Cuban Trauma Society, is a formidable and memorable woman. She reminded me of a young Dr. Anna Ledgerwood, a notable trauma surgeon at Detroit General Hospital. Dr. Larrea has a commanding presence and is a superb orator. She developed and maintains the Cuban trauma registry, and was one of the global investigators in the CRASH2 trial. (Yes, TXA is given in Cuba, and surgeons are very well-versed in current trauma and surgical care). When she talks, everybody stands at attention and listens. The medical care she delivers is very personalized.
During one luncheon with her, she received several patient calls—part of her general surgery practice. She said all her patients have her home phone number, and if they develop problems, she will go to see them anytime, anywhere. She stressed that Cuban medicine has always been gender neutral, and women with good technical and clinical skills progress rapidly in the system. In fact, five of the seven ED physicians are women.
The ED story is not unique to Cuba—but maybe there is a movement afoot to change that. The hospital director recognizes that there are insufficient EM physicians. The current ED staff includes a dedicated director and six other physicians who left their primary training in IM, family practice, or critical care, because they just loved working in the ED.
At the end of conference, there was a special presentation on behalf of the Health Ministry—a decision to establish a Center for Emergency Medicine Education for nurses and physicians. The concept was to grant a “diplomado” after one year of training to physicians who would enter the program after training in other specialties. Will this happen? Is this real? Will the Cuban version of emergency medicine be different from ours?
I don’t know. I’m peering through a shimmering window.
There seems to be excitement about the loosening embargo. But is it really true that doctors only make the equivalent of $65/month (with lodging provided by the government), and taxi drivers have moved up to the Cuban middle class? I was told that schools are now requiring bilingual education, English and Spanish. Yet families remained fractured. Several Cuban colleagues mentioned they had adult children in the US, typically Florida and LA. However, with five-year green cards, relatives living in Cuba can easily go back and forth.
It’s easy to fall in love with Cuba. Try it. Go to the roof patio of the Hotel Ambos Mundos (where Hemingway lived) and have a Cuba Libre while inhaling the beauty of the Havana skyline. If there is a crowd on the roof, now you know how the line works.
We stayed at a Casa Particular, a kind of state-licensed family-run B&B, in Vedado (an upper middle-class, mildly deteriorating neighborhood), with private rooms and bath, and air conditioning and fans. We mingled in the family’s living room, greeting their neighbors coming and going. Two blocks away is a local barber shop, where the charge was “Whatever you think you should give me.” Further around the corner there is an Iranian restaurant with pictures of Gandhi, Einstein, and Marilyn Monroe, along with hookah pipes. On the next block, Jose, a Spanish chef runs a super restaurant he named “Starbien” because he liked the name “Starbucks” but thought his name was better.