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Tuesday, July 20, 2010

Day 05 - Nineteen children seen.

I arrived to the hospital at 8:45AM and I was the first one there. After making my way through the 30-50 families waiting to be seen, I reached the clinic door and it was closed. Not a big deal. I used the time to check out the emergency ward in the next building. It was an air conditioned small building with several rooms that catered to adults and children. The nurses still wear the quintessential nurse's uniform - white dress and white cap. I saw one teach a mother how to rehydrate her child. It is remarkable that dehydration from diarrheal diseases, considered simply a nuisance in most developed nations, leads to the death of nearly two million children in developing countries every year.

Soon the clinic doors opened and headed to Ms. Grant (I gave her an apple that I brought with me from this morning's buffet at the resort.) I was told I couldn't use yesterday's same room. It was the psychiatrist's room and today was her clinic day. I instead set up office in the nurse practitioner's room - she's the women's health person and she does not have clinics on Tuesdays. Playing office roulette is a routine that might change when the Issa Trust Foundation's resident program is in full swing and we have a regular schedule.

I saw 19 patients today. The nurses already knew that I would not see teenagers or do school physicals. A couple of parents knew this too and they registered their children for sick visits, but popped out the school physical form once they were in my office. These actions show the desperate need that these families have for pediatricians in the area. I feel privileged.

I saw a patient with what I thought was leishmaniasis, an infection that is common in tropical countries, and we heard from local doctors that they had been seeing cases here. This is a parasitic infection carried by a fly that thrives in unsanitary environments. After the child is bitten, a painless sore grows slowly and eventually ulcerates (cutaneous leishmaniasis). They can be superinfected, as was the case in my patient, and can spread to involve deeper tissues and possibly even causing death (visceral leishmaniasis). Bad cases of tinea can look similar, but tinea is intensely itchy whereas leishmaniasis is not.. Although the skin sores are ugly and fester for months, they tend to heal on their own albeit leaving behind ugly scars. The treatment is with paromomycin, which provides a cure in more than 90% of kids. The 21-day course costs $10. It is not available in Jamaica. Another treatment is with pentavalent antimony, which costs $60 and was not available either. I prescribed oral and topical ketoconazole and told them to come back in 4 weeks to see if the third-line choice was effective.

The ride home was a little more exciting than usual . I took a cab, and got a lecture from the cab driver about how corrupt the public transport system was. Apparently bus drivers and cab drivers aren't allowed to drive the same roads - each has a permit for a particular road. He called the bus drivers "big shots" who claim all the "good roads".

Lessons learned:
1. Everything runs on Jamaican time. Go with the flow and don't worry, be happy.
2. Learn the second and third-line treatment options for everything. First line therapy may not be available.
3. Make friends with a bus driver. They know all the "top people".
4. If you want to join in the karaoke fun in the resort, remember that they like to change the words - "Give me the beat, boys, and free my soul. I wanna get lost in the REGGAE world and drift away ... "