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Tuesday, September 28, 2010

Sad to say goodbye

It did not really hit me that I finished my one month of pediatric rotation in Jamaica until now when I'm packing my suitcases to head back to the States. What an INCREDIBLE month it has been! I think one month is an adequate amount of time to learn about the culture of medicine here in Jamaica and then becoming comfortable with it to apply to the daily clinic and hospital work.

The one most important thing that I learned after working here for a month is FLEXIBILITY. One needs to be flexible and ready to adapt to work in a less than optimal clinical settings, but still be able to provide the best of care.

There are several things in Jamaica that will always be dear in my heart. Jamaicans are some of the nicest people you'll ever meet in your life. People always greeting you with a smile and passing around the vibe of "no problem" on this island. The food is inargueably delicious, especially the jerk pork at Scotchies (and I'm not even a pork fan). The children here are so adorable in their crisp and colorful uniforms, holding hands and walking to school together (there is something so endearing about this), always politely addressing you as "yes, miss", "no, miss". The lush green vegetations of the mountains and the aqua blue of the Caribbean Sea provide the best scenery that I never get bored off looking out of the window on my daily ride to the hospitals.

I HIGHLY encourage third-year pediatric residents to embark on this awesome journey. I am thankful to the ISSA Trust Foundation and Couples Resort for its sponsorship, to Diane and Stacey who gave me this golden international opportunity, and to Oakland Kaiser Permanente (my residency program) for supporting me with this brand new rotation. I would definitely do this rotation again in a heart beat.

Below is another cutie patient of mine that I won't forget (permission obtained from mother).

Jamaica, you will be missed!

Saturday, September 25, 2010

Week control

I remembered my first day of work here in Jamaica, there was a lot of things that I was not familiar with. Now, more than half way thru this month, I have established a routine and I am comfortable with it. I am more confident now about my clinical diagnoses, which is the predominant tool that one has here, when there is a lack of resources such as Xray, exotic labs and cultures, CT, MRI.

The diagnosis themes for this week are dengue fever, asthma exacerbation, and fungal infection. Dengue fever is real! The outbreak currently reported to have one associated death and 4 confirmed cases of hemorrhagic dengue fever. This week in clinic on one morning, I saw 5 children back to back who ALL came in with complaints of fever, headache, eye pain, and leg pain. These are classic symptoms for dengue fever. The children looked well and there was low concern for hemorrhagic or shock. I sent them to the lab for dengue fever screening which includes dengue, malaria, hepatitis, leptospirosis. I discussed with the parents that there is no specific treatment for dengue, just mostly supportive care with Paracetamol (that is what Tylenol is called here) for fever and/or pain, avoid use of Ibuprofen and aspirin as there is increase risk of bleeding, and to return if there is any signs of bleeding or changes in mental status.

This time of the year with rain and quick changes in weather, asthma exacerbation is quite common here in Jamaica. I actually admitted 2 children this week from clinic to the pediatric ward for management since they failed to improve after Salbutamol nebulizer treatment in the ED. Salbutamol (international nonproprietary name) is just another name for Albuterol (United State adopted name). The children on the ward get nebulizer treatment every 4 hours. Often they are not hooked up to any monitor such as pulse oximetry. They walk around on the ward and play with other children. I was thinking to myself when I rounded on my patients on the ward the next morning about how do we know if they desat when they sleep at night? I guess we just have to rely on lungs exam and how they look clinically. I am happy to report that my 2 children did well, likely to go home after being transitioned to Salbutamol MDI and prescription for Beclomethasone MDI.

This week I saw a girl who was referred to me by the medical mission team from CHOP with random glucose of 430. She has known type 1 DM (diagnosed when she was 6). When I saw her I cannot believe how well she looked for someone with a sugar of 430. She was very pleasant, conversing with me about her diabetes camp experience (they have diabetes camp here!!!!), her insulin regimen at home, and her glucose normally runs between 100-150, so 430 is definitely not normal for her at all. Luckily, she was not ketotic or acidotic based on her labs. We gave her subcutaneous insulin and her glucose decreased to 288, which was still relatively high, despite her well appearance. She was not very happy when I told her that she had to stay in the hospital overnight. However, when I saw her the next day, she was smiling at me and getting ready to go home.

The drive to Castleton clinic

I spent one day this week at Castleton clinic. It is another one of those small clinics in the rural moutainous region of Jamaica. The drive there is rough but extremely beautiful! The lush green vegetations are mesmerizing, resembling a tropical forest. Coconut and banana trees are abundant. I was not surprised to arrive at the clinic and found that it was already packed with patients sitting in a cramped small room waiting patiently to be seen. I WAS surprised when the nurses informed me that there is no water anywhere in the clinic. Thank god for my hand sanitizer! My first patient came in with complaint of ear pain. I asked the nurse for a plastic ear tip but she told me that there was none. I frantically searched my bag and luckily I came up with 2 ear tips. It would have been a challenge to check the ear without an ear tip when someone is complaining of ear pain. For future docs, it is not a bad idea to stock up on ear tips, ear curettes, and hand sanitizers.

She is such a cutie! Look at that smile! (permission obtained from mother for picture)

My time here is Jamaica is winding down and so far it has been an AMAZING experience! I have learned so much and met so many wonderful people. This is such a beautiful country.

Saturday, September 18, 2010

Week hard, play harder

This past week started out rough with a big storm (at least in my opinion) but the native Jamaicans here called it "heavy rain"....not enough wind to call it a storm....but it was pretty scary nonetheless...heavy pouring rain, lighting, and thunders that literally made you jump out of your seat....I have not seen weather like this in a while. Driving to the clinic was of course more challenging with flooding roads and potholes. The drive to the remote River Rock health clinic (located high up in the moutainous areas of inland Jamaica) was so nauseating from dodging potholes, and the width of the road barely enough for two cars to pass. My patient load was somewhat affected on these rainy days, but of course it picked up as soon as the sun came out again. Sometimes midweek I was relieved to learn that Hurricane Igor has diverted away from the Caribbean.

The clinical experience themes for this week are newborn exams and school physicals. Actually, it was somewhat refreshing to see well children after so many acute care visits. I learned that here all children receive BCG at birth or shortly after birth. Varicella vaccine is not readily available so unfortunately it is still not part of the standard vaccination schedule yet.

I have diagnosed quite a few tinea capitis (a very common fungal infection here in Jamaica). What I found interesting was typically in the States, we would initiate oral Griseofulvin for treatment, but here in Jamaica, often the clinicians will prescribe antifungal shampoo and cream as a first line of treatment before considering Griseofulvin. Often cost and unavailability in the pharmacy are the factors. Also monitoring of hepatic function can be difficult as patients often are lost to follow up.

Despite my vigilance about mosquitoes and constant use of repellant, I still managed to get bitten by these crazy and talk about pruritic rash....drives me crazy! There is currently a dengue fever outbreak in Jamaica. I actually saw a patient in the clinic this week that I suspected that he has dengue (fever, headache, eye pain, arthalgia, weakness). Dengue fever is caused by Aedes mosquitoes. It is sometimes also known as "breakbone fever" because of the joint pain. Complications include dengue hemorrhagic fever or dengue shock syndrome. Treatment is supportive care. Luckily, most cases of dengue are either asymptomatic or mild. So far I'm good....crossing my fingers.

I finally met the medical mission team from Children's Hospital Iowa this past week! What an amazing group of people, so incredibly friendly, caring, and fun. The team went to several of the hospitals that I work at, however, on different days, so I never actually worked with the team. Every night, after a long day of hard work, we dine together, share stories, and dance the night away, but of course within a reasonable curfew, so we can all get ready for the next day of work. Today marked the end of the one-week trip. We were all treated to a wonderfully hosted and delicious dinner as a token for our hard work. I will definitely miss them! We will keep in touch most definitely!

As for me, the weekends have turned out quite well since it was the only time I have off. The excursion to Dunn's River Fall was incredible. My adventurous side took me sailing, kayaking, beach volleyball, hydraulic biking, and a feeble attempt at water skiing (it turned out my feet were too small to fit into the skiing shoes and I was consider high risk since I cannot swim...still working on that). I also got a chance to eat authenic jerk chicken and pork at one of the best jerk restaurants in Jamaica (Scotchies!).

I cannot believe that I only have about 10 days left here in Jamaica. Where did the time go? This upcoming week I will meet the medical mission team from Children's Hospital Philadelphia.

Until next time....

Friday, September 10, 2010

Week 1...learning the ropes

My first week in Jamaica has been extremely BUSY! I worked at three hospitals with adjacent outpatient clinics on different days of the week, saw a ton of patients, befriended many Jamaican medical staffs, picked up quite a few native Jamaican terms, learned to tolerate the humidity, AND already am the victim to mosquito bites despite my repellant. I am very much aware that there is currently a dengue fever outbreak warning in Jamaica.

The diagnosis themes for this week are skin infection, skin infection, AND skin infection. I honestly have never seen so many cases of impetigo and furuncles/carbuncles in my entire life. I've written god knows how many prescriptions for Keflex. Skin infection is VERY common here in Jamaica considering its tropical weather that is quite inviting for the mosquitoes. The children play outside a lot and wear short pants and skirts making them more susceptible to mosquitoes. Mosquito bites are incredibly ITCHY (I know!), scratching breaks the skin barrier, and leads to superimposed bacterial infection. Many children have scarring on their arms and legs from recurrent skin infections such as the picture here (I have obtained permission from the patient and her mother for taking the picture).

The clinics are very busy. There is always a long line of patients to been seen way before the clinic even opens. Often, I don't even have time for lunch because as soon as I'm done with one patient, the next one comes in, and I just feel bad that they have been waiting for a long time so I just kept on going. At Port Maria clinic, I'm essentially the ONLY pediatrician there, so I get all the referrals from the main health complex and from the ER. One day I saw as much as 23 patients! Insane right? On the contrary, at Annotto Bay clinic, the workload is somewhat lighter since there are one regular pediatrician (Dr. Ramos) and one Jamaican resident working alongside with me.

My office and exam room in Port Maria

The biggest adjustment for me was going back to paper medical record style. Deciphering handwritings from previous physicians who documented in the docket (medical chart) can be so tricky. Often the dockets are incomplete or out of order and can take sometime to figure out what has been going on with the child. Writing in the chart and prescriptions also takes time. Sometimes I feel so pressed when I know there is probably a long line of patient waiting outside my exam room. To my fellow residents back home in Oakland, California...we are so blessed with our electronic medical record!

Another challenge for me this week was understanding the native accent. Jamaicans speak English as well as their native dialect called Patois. Sometimes the accent is heavy and I can barely understand, but I'm learning. After I talked to some of the medical staffs, here are somethings that I've picked up... "water bump" means pustule that ruptured, "tonic" means appetite stimulant (mothers keep asking me to prescribe vitamins as "tonic" for their children), "du du" means poop.....

The drive to the hospitals is variably long (anywhere from 30-minute to 2-hour drive). The views of the majestic aqua Caribbean sea and the lush green coconut and banana trees on the periphery somehow miraculously suppress my car sickness and made the drive quite pleasant.
I have yet to use my Meclizine.

Coconut and banana trees, Caribbean sea (along the drive to Port Antonio)

My plans for this weekend: hopefully testing out the Caribbean water with some fun water sports and finally meeting the medical team from Children's Hospital Iowa.

Until next week.....

Sunday, September 5, 2010

Arrival to Jamaica

After half a day of traveling from San Jose, California, 2 stops, and being delayed at Miami Airport, I finally arrived to Jamaica very very late last night. On top of that, my check-in baggage was missing, so I spent my first night in Jamaica unbathed and without any clothing change. However, when I arrived at the resort, everyone here was so incredibly accomodating and understanding. The manager of the resort even offered me a free shopping spree at the gift shop so I can have change of clothes. I moved into the private villa today, and it is FABULOUS! I was informed by the front desk that my baggage should be delivered to the resort this evening....thank goodness! I was very worried since I have my clothes, toiletry, books, medications, and medical equipments in that bag. Anyhow, rough start but I'm so thankful to be here. Jamaica is so beautiful! I'm very excited to start work tomorrow. Let the month begin!