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Friday, May 27, 2011

Week 3&4: Port Maria and Port Antonio

Port Antonio

My last week of Port Antonio Hospital was a slow day on the ward as well as clinic, having only 2 patients to be seen in clinic which was a contrast to the previous week which had us working with no breaks up until the moment we left. One was a young girl I diagnosed with inguinal hernia and referred to the Surgeon down the hall and the other was a 7 month old baby who was unable to make it to the appointment but had been referred for evaluation for achondroplasia. I listened to the social worker who was there representing the mother and she explained how the mother had come several weeks to see a pediatrician but that the weeks she had come, there were no pediatricians available and today both were unable to make it due to a complicated social situation. The baby was apparently disproportionate in size with short extremities and a description that fit but had not been formally seen or diagnosed with a genetic condition. Of note, there are also no medical geneticists on the island in addition to other pediatric subspecialties.

On the way back from Port Antonio, the Ministry of Health employee who was kind enough to drive me back the two hours back to the resort explained to me all of the different type of plants and fruit trees lining the road ranging from banana trees, breadfruit trees, mango trees, and ackee trees. I expressed my interest in trying ackee and saltfish which is a national Jamaican dish. He stated the dish was delicious with breadfruit, but he warned me that ackee that is picked too early can be poisonous. Other people who call this dish the Jamaican Rundown, told me that one has to be careful about who you buy your ackee from but that the dish is very delicious. I asked one of the doctors at Annotto Bay about this, and she told me there was recently an outbreak in ackee poisonings this past year with a spike in the number of cases. Due to ingestion of ackee that has not fully matured, the toxin Hypoglycin will lead to hypoglycemia and symptoms of vomiting, stomach cramps, and diarrhea and in severe rare cases, coma or death. I found this useful information to know and has somewhat dampened my curiosity in trying this fruit.

Ackee Fruit

The next two weeks at Port Maria were busy and a week after the departure of my wonderful colleague Dr. Hack, I found myself incredibly busy seeing 26 patients in clinic one day from 9 AM to 4PM. I realized how just like at the end of any rotation, you start feeling comfortable with how things are run right when it's about time to leave. One of my more complicated cases was a preadolescent boy diagnosed several months ago with HIV but who was not aware about his diagnosis. He came in with 3 weeks of cough and a rash which looked like tinea versicolor. I obtained a chest xray which revealed an infiltrate keeping in mind that the mother stated he had been on several weeks of an antibiotic which finished a week ago, but now was not on any medications and that his first appointment to discuss his condition was next month. None of this information was located in my paper chart and without any previous labs or other information about which antibiotic he previously was on, I discussed a plan of care with the ER doctor who knew him well and sent him to the A&E for further work-up including a CBC, viral load, CD4 count and initiation of antibiotics.

The rest of my clinic visits at Port Maria in the last two weeks were the same ranging from well checks, scabies, deworming, a variety of skin rashes and referrals to other hospitals for conditions requiring surgical intervention. Three medications that I felt helpful to know were Tropovite Vitamin Drops which contain Vitamin D, Hemafed which contains iron, and Rid Cream for scabies and lice. I would ask to peruse the pharmacy counters before clinic on days I had time because knowing which medications were available in the pharmacy is invaluable to avoid having families paying out of pocket for medications at private pharmacies when alternatives can be easily picked up at no cost here.

Another thing I take for granted in the states are scheduled appointments. I find it hard to take breaks knowing that patients arrive at 9 or 10 in the morning for an appointment. Once a parent even pretended his son was another patient so that he could be seen earlier and I only discovered this after the parent of the actual child asked why they had not been seen yet. Due to this, I have made it a habit of asking the parent the child's birthdate before starting the visit. I've also gotten used to adults randomly walking into my room, even in the middle of a child well check, and start telling me their ailments. I always have to gently cut them off and explain to them that the family practitioner across the hall can aid them and that they have to wait for their turn.

Long Lines

Here are a couple of photos of 2 adorable children seen in the clinic: (written consent obtained from parents).

Week 2 - Annotto Bay and Port Antonio

During the second week of our stay, I enjoyed rounding with Dr. Fisher and the ward team on the inpatient service. There were several interesting cases ranging from rule out kawasaki disease, seizure disorders, and asthma exacerbations. There was one case where a parent believed that bad spirits were causing the medical disorder, and did not believe giving the anti-epileptic medications recommended to treat the disorder would help, asking instead to take her child out of the hospital to see a medicine man that day. One of the doctors and an ambulance worker explained to me that there are people with voodoo beliefs and they can be suspicious of medical treatment, preferring to go instead to those they believe can make the bad spirits go away. This can present as a challenge for medical doctors who are trying to give a child the medical treatment they need and to educate a parent about the condition.

Annotto Bay Ward

The following day, we had a short clinic day where I saw several well checks, a follow up for sickle cell disease, and a girl diagnosed and treated for kawasaki disease whose coronary aneurysm had resolved and was getting ready to graduate the clinic. I was surprised to hear that there was no clinic in the afternoon, and then was informed of a special event that afternoon where the ISSA Trust Foundation was donating incubators and a combination incubator and ventilator to Annotto Bay! Everyone was very excited because this equipment would help improve the care of premature babies in keeping them warm instead of having to improvise by wrapping them in cotton which is not as effective in maintaining their temperature. It was a very exciting day for Annotto Bay!

Here is a great article on the event ~ Incubators for Annotto Bay.

The following day, we headed towards Port Antonio which was a 2 hour drive. We were very thankful for the kind employees who drove us back and forth to this hospital where there are no pediatricians. We helped run rounds where we saw a sick baby with abnormal electrolytes and a boy with sickle cell pain crisis and acute chest syndrome. We made recommendations to get a CBC, BCx, CXR, and give oxygen and were concerned enough about the progression of one of the children that we called over to Annotto Bay for a possible transfer. I was informed later that the baby's electrolytes normalized but the patient with sickle cell ended up having to be transferred to Bustamante. It is nice to know that we can easily call the ward team or Dr. Ramos with any questions about patients who give us reason to be concerned. One thing that struck me after having rounded on the patient with sickle cell was that there are no pediatric subspecialists on the island particularly hematologist-oncologists. That is still a fact that I am trying to digest.

Afterwards, we attended to clinic and did not eat lunch in order to see all the patients there. We ended up having to split one room which felt chaotic but were able to see everyone by the time we had to leave. Overall, we agreed that there seems to be a great need for pediatricians at Port Antonio and were thankful for the experience to participate in the care of children there.

Port Antonio Ward

That weekend, we had the pleasure of having dinner with Diane Pollard, Dr. McConkey, her husband, and two Biomed volunteers. It was such an inspiration to hear their ideas and new developments coming in the future for the hospitals and the rotation that will make a positive impact by improving pediatric care. During my experience here, I have had times where I initially felt powerless as a physician when certain resources were not available, but after these weeks, I realize it is empowering to know that one can help out by donating needed resources, spreading awareness, or volunteering.

After a long busy week, we were able to enjoy Jamaica by going bobsledding and ziplining through the Jamaican Rainforest at Magic Mountain in Ochos Rios. Here is a beautiful view from a sky lift showing the coast.

Tuesday, May 17, 2011

week 3

Week 3
Day 1, Port Maria
The weekend was awesome!! Scuba diving at the resort, and ziplining and bobsled riding at Mystic Mountain Rainforest were amazing!! We also had dinner with Diane Pollard, Dr. McConkey, her husband , and two Biomed volunteers. It was lovely to meet them all and learn about the many things that Issa Trust Foundation does to improve medical care in Jamaica.
Today was back to work. Super busy day today. I saw 2 children who had stepped on nails, 1 had developed an abscess which I drained. I saw a child with spina bifida who was having chronic knee pain. An overweight male with chronic knee pain who I was sure who had have a SCFE who did not. Saw multiple other lacerations which were too old to repair. I saw a little girl with a history of macrocephaly and recurrent and persistent thrush. In my time here I have become more reliant on my clinical skills and my instincts. I have also found myself treating with antibiotics more than I would at home, especially for pharyngitis symptoms after learning there is a significant amount of rheumatic fever here and there is no rapid strep or throat cultures available. Perhaps, the biggest surprise of the day was when a mother of a 3 month old boy asked me to be her child’s godmother! I felt honored, but unfortunately as I am leaving in 2 days, I could not.

Day 2, Port Maria,-My Last Day
Today I felt as if I was in an ED and not a clinic. Multiple cases of asthma exacerbations. A case of abdominal pain which is challenging to evaluate without imaging. The girl kept crying that her stomach hurt, but had only mild tenderness on exam. I did an AXR which showed lots of stool, asked for bloodwork, and kept her for several hours for observation. Had to rely on my exam and the wbc alone to r/o appendicitis. Thankfully after several hours her pain and tenderness resolved

This has been an amazing opportunity in so many ways. It is a great learning experience to evaluate and treat children without so many of the tools that you become reliant on. It is fascinating to learn about the healthcare system in Jamaica. It is interesting work in a different culture and really getting to know the people. The resort is absolutely amazing, the food was some of the best I have ever had, the staff could have not have been any nicer or more helpful, and the activities were awesome. I have definitely gotten a little spoiled at nighttime and on the weekends here!!
I would like to thank Diane Pollard and Dr. McConkey for all of their hard work in setting up this rotation. I am grateful to the medical staff and all of the different sites for helping us out with our endless questions. Thank you to all of our kind drivers!!! Thanks to The Couples Tower Isle and the amazing staff for hosting us.
A very special thank you to Dr. Chung Lee, my colleague and friend for the last 18 days!! Thanks for all of your help, and all of the fun memories!! I hope to see you again!!!

Sunday, May 15, 2011

end of week 2

Friday, Port Antonio
Today was our first day in Port Antonio as we were unable to go last week due to lack of transportation.
Very interesting day.
In the morning , we met with the director of the hospital, Dr. Davis who gave us an overview of the hospital. It was very helpful and informative.
Then we went to the pediatric ward and rounded on the patients there with an intern. There were some sick children there. For example, there was a patient with sickle cell disease, fever, and acute chest. We suggested obtaining some bloodwork, a chest xray, giving oxygen, and maximizing pain control. There was 1 week old baby brought in for lethargy who had severe electrolyte abnormalities, metabolic acidosis and elevated direct bilirubin We asked to repeat the blood work, and if it was still abnormal recommended transfer to Annotto Bay where the pediatricians could oversee the care of this child.
In the afternoon, we went to the pediatric clinic. As pediatricians are consultants, many of these cases were not so straight-forward and required some time and thought. I saw a child with nephritic syndrome, a girl with intermittent fevers x 5 months, a girl who had a lethargic episode 2 weeks prior among other cases.
I felt very useful at Port Antonio, which was a great feeling. Kind of nice to be in a place where pediatricians are so needed. Our driver that day was amazing, so kind to us. She totally went out of her way for us (Port Antonio is almost 2h away), and ensured we met with Dr. Davis.

end of week 2

Wednesday and Thursday, Annotto Bay
So on Wednesday morning my colleague went to Pediatric rounds at the Pediatric Ward, and I went to the "A and E" Department (Accident and Emergency Deaprtment). There ED works differently in ours. The physicians actually quickly triage the patients, and if the child does not warrant "ER" criteria, they are sent to clinics. I guess this is an effective way to decongest the ERs, because I only saw one child, who ended up having otitis media. Still, it was interesting to see how the A & E functions and tot alk to the other doctors. If you need labs done, your draaw them yourself. Ivs are completely different and there are no vacutainers or butterfly needles. If you want to give a patient a medication, you write down the order, and the patient then brings that to the ER to get to get the medication. They can do xrays and ulatrsounds, but they have no access to CT scanners. ER doctors read their own radiologic studies. It is a process to get a radiolgist to read something.
In talking with the Jamaican doctors, I learned more about the training system. You got medical school directly after highschool. Medical school is 6 years. Then you do 1.5 years of internship. Then you can start to work in the field you want to do residency in, but you need to get recommendations before you can do your training. REsidency is pretty competitive to get for most things, including pediatrics. Most of them take the USMLE exams just in case they train in the US.
Thursday, Annotto Bay
Today we had clinic which was very busy last week, but only a half day today. Saw a variety of newborn checks and sick children. Alot of children today with slow (or no) weight gain. There are no growth charts in the patinet's charts due to lack of resources, so it is hard to tell if they fell of thir curve or not. Just have to look back and compare to previous weights. The day was shortened as there was a ceremony to celebrate the Issa Trust Foundation dontain some ventilatos and incubators to the hospital! Supplies greatly needed!!

Week 2 - Port Maria

Hello again from Jamaica!

The beginning of this week we spent two days in Port Maria with my colleague spending time in the A&E and myself working in the clinic. Here's a photo of the front of the clinic. Each day we come there is a line of people who have been there since 8 am waiting for clinic to open. It seems to be first come, first serve with the clinic starting at 9 am.

It was Child's Day on Tuesday so we got to see the children for their well checks. While seeing babies, I found a measuring tape useful to have since we measure the length and head circumference of each baby ourselves. I looked up each growth percentile in my Harriet Lane to ensure that the babies were growing well. There aren't growth charts in all of the paper chart files due to resources so we document everything by percentile in the paper charts which is helpful for the next person who sees them in terms of following a growth trend. Also, if you think a baby is jaundiced and you want a bilirubin level, after 11 AM you would have to draw it yourself in clinic and have it dropped off at the lab. I was really surprised to hear from the lab how much blood is actually needed for a bili draw as the lab or nurses usually draw it at my home institution. Dr. San and Dr. Win have been a great help in asking questions about what is available in the pharmacy here and what is used to treat patients for certain diseases. The cases we saw ranged from scabies to viral gastroenteritis to parental concerns about worms.

One thing I take for granted in the states are strep swabs. In the states, if you hear a complaint of sore throat and suspect strep, you can get a strep screen and if it's positive treat, which is important to prevent the complication of rheumatic fever. Here, there is no rapid strep screen so if you suspect, you treat. Dr. Win told us that there have been cases of rheumatic fever this past year and it reminded me of the child I saw last week who was being treated with month shots of penicillin for the past year after being diagnosed with rheumatic fever. I have only seen one case in the states of Rheumatic Fever and here it is definitely more prevalent.

On the second day of clinic, I saw this adorable 2 year old boy who had right periorbital cellulitis with bilateral bacterial conjunctivitis. I had the child admitted for IV antibiotics and observation and found out from the other ER doctors to refer him to A&E for admission. Port Maria also has a ward which we haven't seen yet and I assume he went there since I did not see him the following day at Annoto Bay. One of the benefits of having electronic medical records back at home is being able to follow up on kids to ensure that they are seen and admitted.

After a busy day at the clinic, we have our 30 minute drive back to the resort. Here is a view of driving through Port Maria where you can see different stores and daily life.

At the end of the day, it is always so nice to come back to the resort. We have been welcomed by such friendly people and my colleague and I are always amazed of the beauty of this country.

Tuesday, May 10, 2011

week 2 day 2

So today we were again at Port Maria. I again saw mostly ED patients and a handful of clinic patients. I had an interesting case with a 4 yo M with bilataerl axillary abscesses which I was happy to drain. Interesting to make do with the resources that they have. The way we do procedures is very different than the way some of them are done here, in ways involving resources and in some ways not affected by resources b ut just in the way we practice. Interesting to see differences.

Monday, May 9, 2011

week 2 day 1

soo after an awesome weekend of scuba diving, snorkeling, sailing, and realxing, back to work today. Today we went back to Port Maria. Felt much more comfrortable this week as compared to last week, as we knew where to go, who to talk to. I worked in the hospital and saw ED patients and also helped out the clinic and saw some of those patients as well. Pretty busy day. Saw a range of illness from URIs to many skin infections to knee pain. Kind of challenging to figure out how to manage patients without laboratory tests. Really relying on clinic skills. The patients are so appreciative and friendly.

Thursday, May 5, 2011

week 1 - welcome to Jamaica :)

Hello from Jamaica! It has been a wonderful first week and after getting settled in, we started our first day of clinic this Tuesday at Port Maria's clinic and A&E department. We split up our time between the A&E and clinic but the ED was slow with not much pedi cases so we both ended up working the clinic which was busy with pedi patients. I ended up seeing 9 patients or so the first day and it was pretty busy in the morning! One difference I noticed was the lab is open in the morning for several hours and if you miss that window, you have to draw your own labs which we ended up having to do. A CBC is fast to run with results in 10 minutes, but we sent for coags which ended up being a send out and can take 3-4 days and cultures even longer. It makes you really think about whether you really need those labs and how to manage your patient given your clinical judgement knowing that it may take a while for labs to come back. I saw several gastroenteritis cases, a primary herpes gingivostomatitis, asthma exacerbations, and well checks. It all seemed similar to urgent care clinic that I see back in the States. In the beginning of the day, there was a long line outside of the clinic but by the afternoon we were able to finish seeing everyone.

The next day we went to Annoto Bay Health Center and participated in rounds on the ward. The set up had all the beds and cribs in one room with a mixture of pediatric ward, NICU, and well baby! I was really impressed by the rounding, the residents, and Dr. Ramos whose teaching was thorough and engaging. There were interesting cases from r/o sepsis, r/o ITP, RDS, IDM to discuss and it was basically sit down rounds. There is also a need for certain medical equipment including neonatal blood pressure cuffs which the physicians are working on getting and hopefully will come soon.

Today we had clinic at Annoto Bay Clinic and again saw a huge line of patients until everyone was seen. I saw a kid for a well check with a h/o rheumatic fever which is more prevalent here in Jamaica, as well as newborn well checks and urgent care visits. I did spend time making sure to give dental education for my patients during their well checks since there is not as much access to dentists here. It has so far been an amazing experience thus far and we have been so grateful for this opportunity!

days 2 and 3

so yesterday we went to Annotto Bay, a level B hospital, more advanced to Porta Maira. The pediatric Ward was very interesting, It was a NICU, well baby nusrery, and pediatrics ward in one large room. The residents were very welcoming and oriented us to t he facility. We saw the aptients in the Ward and then we got to sit in on the rounds with Dr. Ramos, Dr. Ramos is an amazing teacher. The residents were a mixture of general doctors and pediatric residents.

Today we went back to Annotto Bay and worked in the clinic which was very busy. I saw a variety of cases ranging from pulmonary stenosis with CHF to worms, to lots of well baby newborn exams. Patients were very patient and appreciative. Children adorable!!

the food at the resort is absolutely phenomenal!! fell like i'm eating iron chef food every night!!

Tuesday, May 3, 2011

first day

so today was our first day at port maria!! until now we have been enjoying the luxurious resort with beautiful pools, beacches and fun activities, and of course the yummy food. today it was time to start working!
we arrived at port maria this morning, to see a line of patients waiting for us. my colleague went to the clinic and was immediately very busy seeing patients. I was stationed in the hospital, and only saw 1 patient in 2 hours. Then I asked to help out the clinic which was very busy, and then i got buisy. I saw a variety of patients ranging from gastroenteritis, constipation, rashes, and an abscess s/p dog bite. this hospital was very small and resources limited, but we did our best. took a little detective work to find the right people and supplies, but te other doctors and nurses were very helpful and friendly. it was good to start doing what i came here to do. funny to be in a country where we are "specialists." parents seemed so grateful to have seen a pediatrician.