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Friday, August 6, 2010

Independence Day in Annatto Bay Hospital

It's Friday and I confess I am looking forward to the weekend. Today Jamaica celebrates Independence Day, 48 years of Independence from Britain. The pedestrian and vehicular traffic was very light and many people were dressed in the Jamaican colors of green, black and gold; I did the best I could, since I packed light. Er..., well..... light by female standards.

The photos are of Tower Isle Beach, taken from the dining room of The Couples Resort.

On the drive into Annatto Bay, The Jamaica Constabulary Force (that's the police) were parading in ceremonial uniform near the Annatto Bay town center. The road was closed for the ceremony; Steve the driver seemed to know this and made a detour before I knew what was happenning. I asked about the detour and he pointed out the parade ceremony. Steve is a good person to ask about local information and customs. He has lived all his life in this part of Jamaica.

On the issue of transportation, unlike in the USA , the average person does not own a car. This is also a rural community. Many people use minibuses and taxis to get around; transportation costs are high for the average person. Licensed taxis are cars with red license plates and take multiple passengers. A relatively short trip may cost J$ 80 to J$ 250 (the currency exchange rate is about J$ 85 to US$ 1). Be aware of this as you see patients and make requests that involve travelling for tests, follow up etc. Some patients may not return for follow up if they have don't the money for the trip and no one to bring them. If they have to buy medications that also adds to the cost of getting care.

The morning was spent at the pediatric ward with Dr Ramos and staff. The sick preterm triplet who was critically ill, was transported by air ( military helicopter)to the Bustamante Hospital for Children in Kingston the previous evening. I thought it was pretty cool that a military helicopter would come for a 1500 gm premie! Made me (neonatologist) feel good. Anyway, the region needs at least 2 transport isolettes with ventilators and monitor, so babies who are critically in need respiratory support can be transported by ground. The cost of the equipment is much less that the resources used for use of a military helicopter and would be a good investment financially and in reducing morbidity and mortality.

On rounds, there were several cases of gastroenteritis and Dr Ramos dicussed the global impact of mortality from gastroenteritis. US pediatric residents need to be aware of the management of gastroenteritis in low resource countries. Dr Ramos gave clear and concise instruction to the mothers on using the oral rehydration salt solution. Other cases on the ward- congenital heart disease with endocarditis, respiratory distress in LGA infant of a diabetic, term baby with neonatl seizures, and a few growing premies. There is a need for isolettes to prevent the environmental temp swings with the babies. It makes for multiple evaluation and treatment for sepsis.

I went to do rounds on the maternity floor to see the normal term newborns. The mothers co-bed with their babies in a shared open ward. No individual private rooms, or even double rooms, no nursery to send the baby for bath, vitals and blood tests, or for mother get some sleep. Mothers provide ALL the the care for the baby, the nurse is there to monitor for any problems. I was only able to see 1 mother and the baby was around 29 hrs old and was for discharge. The mother and baby chart were in the same file. That was soo...... convenient! No searching for maternal records and labs!

This lady had 3 previous children, last delivery 7 yrs before, had prenatal care- 14 visits and told me this was her last child. She used contraception and spaced her pregnancies. She was breastfeeding but said the baby was sleepy. I asked her how she handled this and her response....."Ah wake her up and force the tittie in her mouth". Just exactly what a lactation consultant would have advised!

Annatto Bay Hospital's breastfeeding rate is 100% and they have been designated a Baby Friendly Hospital. They achieive this without lactation consultants, breastfeeding classes, breastpumps and all the other resources of wealthy US hospitals. The co-bedding made it convenient for breastfeeding. The communal atmosphere provides support to the mothers for breastfeeding and I'm sure the experienced mothers give advice to the less experienced. I wonder what would happen to the woman who showed up with formula and a bottle? Probably she would have no friendly looks from the other moms! Formula is very expensive, strongly discouraged and the time and cost to boil water and sterilze bottles is prohibitive

Breastfeeding here is the norm, is natural and women can breasfeed wherever and whenever they need to do so. Fellows, if in the middle of your conversation with a mother, a mammary gland appears, don't be shocked. Just keep talking, go with the flow. On the maternity ward, there is no detailed scrutiny of urine output or weight loss and there is no multiple lab testing as in the US. Mothers have uninterrupted time to nurse the baby.

I also noticed at all the pediatric wards that I visited, (St Anns Bay,Port Maria, Annatto Bay, Port Antonio) the children who were feeling better were free to roam and play outside ( even if it means rolling around with the IV pole); they were often not in bed- especially the boys! They may be outside somewhere in the vicinity with the mother. The mothers were often there or had recently been there, children wore their own clothes from home, not hospital issued gowns. A nurse may dispense an oral medication and have the mother give it. Mothers are welcomed and feel encourged to stay. I wonder if perhaps all this sense of normalcy contriutes positively to the child's recovery.

My weekend plans... I'm expecting family to visit and I am looking forward to that cos I've been lonely all week!

Thursday, August 5, 2010

Thursday August 5, Port Antonio Hospital














Port Antonio is one of the most beautiful spots in Jamaica. These photographs were taken from the parking lot of the hospital.

.....Well, today was one of those days, when things just don't happen as planned. Most of the day was spent on the road driving between Ocho Rios and Port Antonio.

This morning, there was an accident on the main road near Port Maria, so the driver, Steve, was delayed in picking me up. It's a long drive to Port Antonio, so Steve planned to wait until rounds and clinic were complete, then we would return to Ocho Rios. We expected to be done by 1 or 2 pm.

We were just about approaching the Port Antonio Hospital when he received an urgent call that he was needed at Annatto Bay Hospital. The urgency was related to the need to transport a sick preemie to St Anns Bay Hospital. When I arrived on the pediatric ward, the nurse informed me that rounds were already done and that the registrar ,(Dr Fazul) was in Accident and Emergency Room.

The nurse was very good and she quickly walked me around to every one of the nine patients. Her oral delivery of the history, lab results and management plan- all from memory, was quite impressive. I contacted with the Port Antonio Hosp SMO about the situation (ie the driver needs to leave,)- they had one peds patient scheduled for me, but the patient was a no-show and could not be reached, so I explained I would to leave and return next week. I thought it best to head back to Annatto Bay Hospital; may be I could assist with the preemie.

On the way back, I was on the phone with the Administrator at Annatto Bay Hospital; seems the plans for the baby's transfer had changed. There was no plan to transfer, since the baby was unstable; they were unable to give any details about the baby.
I later found out the unstable baby was one of the triplets. Drs Fisher and staff were working to stabilize the patient, Dr Ramos, also came to assist. We discussed the problems of prematurity. Sometimes even with the best efforts, some babies do not do well. We are hoping that this little one will respond to treatment and fully recover.


There is a need for compatible BP cuffs to check blood pressure. Neither the Welch-Allyn cuffs and the disposable Critikon cuffs fit the BP machine at Annatto Bay.
Maybe a Dynamap machine would be good, or find a fitting that would adapt the machine for use with current BP cuffs.

Also needed, skin probes for the leads- the kind with the metal snap that are used on many ECG machines. These probes are too large for the preemies- but they work with the machine they have at present.
Also much needed- blood transfusion kits with filter and IV infusion pumps with compatible tubing.

Jamaica Pediatric Mission: August 4th , 2010 Port Maria Clinic

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