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Saturday, April 30, 2011

Last thoughts on my extra last day with Issa- April 2011

Ok, so my flight was cancelled and I got an extra beautiful day in Jamaica. How awesome is that!

So this is likely my last blog. My last week was short but still great. Monday was Easter Monday, a holiday, and Friday I got the day off to finish and do any last minute things before I left.

On Tuesday, I saw about 30 kids. It was like the post holiday/school's out rush as the week before there were only about 20. Tuesdays at Port Maria clinic has been the busiest days this month. You average about 25 patients. David and I figured out that maybe on those days we should both go to the clinic so that people who are there from 8am aren't getting too upset when they are still there at 3pm being seen.

The picture above (taken with permission from Mom) is of a little girl I saw twice this month. Initially she came in for recurrent oral thrush and a neck rash that looked like tinea versicolor. She was on the appropriate medications and mom was using it correctly so I was a little curious as to why it hadn't been getting better. I asked mom about her history (was worried about maybe some immunodeficiency, HIV etc) and sent her to get a CBC. Of course blood work wasn't being done that day so mom was suppose to come back to see me once she got the results and to continue using the medication.

As is obvious in the picture, this child also had a large head. She had already been sent to have a head ultrasound for hydrocephalus, even though there had been no documented hydrocephalus or even head circumference in the chart...EVER. Mom reported that the ultrasound was normal.

On Tuesday, mom returned with the CBC results and a bottle of medicine that she said the child had been on daily since January for a vaginal discharge. It was Septra. This baby had been on antibiotics since January for what it didn't sound like was a UTI or any type of VUR; The reason for the continual use was nothing more than a miscommunication. Mom was told to give the medication until it was finished (something we may say to our patients if we wrote a prescription for a specific amount). Unfortunately, she was given a large bottle of the medication and it was not finished. Her CBC was not grossly abnormal except for a slight anemia but I felt I knew the culprit for the recurrent thrush (I hope). So I had mom discontinue the antibiotics and return in 1-2 weeks.

I also did a head circumference and would like her to have serial head checks because unfortunately mom cannot afford a CT scan right away. I do not feel that this child's head is normal and fear that it will progress until she starts having sunsetting of her eyes (they are, as is obvious in the pic, already large and somewhat bulging). She is currently developmentally normal and a delightful child. Because this was weighing so heavily on my mind I asked the pediatrician at Annotto Bay on Wednesday what he would do. He recommended just referring her to Neurosurgery in Kingston and letting them sort out imaging. Great advice! I would never do that at home because for a referral to neurosurgery I would likely need imaging to prove that a neurosurgical problem exists and not just a referral for macrosomia. Would like to know that this baby continues to do well.

On Wednesday and Thursday we saw a lot fewer patients at Annotto Bay than usual. We finished both days a little early and were excited that we may get to return to the hotel earlier to do some activities if possible; That didn't happen. On Wednesday, we had a detour to the garage the hospitals use to work on the vehicle's brakes (pic above is the garage). On Thursday, our transportation that the hospital arranged for us was in Kingston and we ended up waiting for about 3 hours since they had delays getting back.

My final thought: Many of the problems here in Jamaica with health care stem from lack of resources. As you read blogs you hear about a hospital with no mechanical ventilators, makeshift CPAP, no sub specialists, labs that cannot do urinalyses, clinics not equipped for pelvic exams. They are all needed but aren't things that we can readily provide. However, there is one area I feel that we can leave an imprint in addition to our service. At Port Maria, the only vital taken is a weight. There are growth charts up to the age of 2 with only weight on SOME of the charts. I did not see them in the charts at Annotto Bay or Port Antonio BUT at Annotto Bay, all vitals incl temp are done and we were provided a copy of full growth charts (birth to 20, females and boys, wt, length and HC).

Maybe we can work to integrate full growth charts in EVERY chart as well as encourage full measurements incl temp, BP (age over 3 and would require they have the appropriate BP cuffs), HC, RR and weight. By doing this we could pick up the infants like the one admitted at Annotto Bay with meningitis at all the centers (the infant was clinically normal, mom came for well infant/newborn check and this was only identified because of a fever documented in clinic). We could avoid things like referral for 2 children who 'look thin with ribs showing' when they are growing well (50-75th percentile) and likely having more rapid height gain and from missing children that are failure to thrive because they have not been plotted in their last few visits. This is just my 2 cents and hope that maybe we can accomplish that.

Thanks again to Diane and Couples resort/Issa Trust Foundation for an amazing experience.

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