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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.

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