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Monday, December 10, 2012

It's my last night in Jamaica, and I have had a great two weeks working here!  I have learned a lot about the medical system here in Jamaica and have seen a lot of patients!  I'll give a quick run down of the way my weeks were set up, followed by some things that I enjoyed most about the resort, and finally some helpful cultural/medical tips that are different from how things typically go at home!

Monday/Tuesday: Port Maria
This is a rural hospital and is the closest of the three locations.  ~ 30minutes by car.  My day typically went from ~8am-4pm, occasionally finishing a little sooner.  I spent a little bit of time up in the ward, but mostly I worked in a room right around the corner from the A&E (Accident and Emergency) seeing patients (mostly patients from the A&E but sometimes also patients that were being seen for immunizations in the outpatient setting that nursing also thought could benefit from seeing a doctor).  Sometimes it was a little slow at the very beginning of the day, but it always picked up and then there was never a lack of patients to be seen before the end of the day.  I probably saw ~10-20 patients per day.  The volume here was definitely a plus.  One of the general doctors was staffing the A&E, which was definitely a benefit because especially at the beginning, I had questions about what medications were available in the pharmacy, how to get someone referred to get a hearing test, get an echo, or see a subspecialist.  I think that is one of the more challenging aspects of the trip-- just figuring out how to navigate the healthcare system here.  The general doctors in the A&E were very helpful.  Sometimes with the volume of patients, it would take some time to find someone to get the answer that I needed for the patient.  Here I wouldn't recommend bringing the computer with to log patients as you are seeing them (if you are by yourself, because when I had a question to be on the safe side i would bring anything valuable with me in my bag into the A&E to find the general doctor to get the answer I needed... the computer is just one extra thing to carry for this).  Other highlights of Port Maria were getting to do blood draws, an I&D of an abscess, and start an IV (as here it is the doctors that do these things rather than nursing/ancillary staff). 

Annotto Bay
I also had a great but different experience at Annotto Bay.  Annotto Bay had a lot of damage from Hurricane Sandy-- the roof blew off the pediatric ward and many other buildings.  Currently they are working in a makeshift pediatric ward, while they are working to repair what has been damaged.  Currently, they are working on the building that was the A&E department. There are two general doctors that were working there each morning and then Dr. Ramos (a pediatrician) would come to round.  It was wonderful working with all of them.  Rounds were a great way to gain some education and insight into how things are done here in Jamaica.  Dr. Ramos also highlights some differences between medical practice and the culture here in Jamaica and what we see in the Unites States.  This educational aspect was very helpful in understanding the people here and gave me more guidance in the information I should be giving for anticipatory guidance for well visits and for caring for common medical conditions here.  On Wednesdays, I would see a couple of the inpatient cases then would round with Dr Ramos and the team.  Generally, Wednesdays finished in the early afternoon.  On Thursdays, I would arrive and go straight to the clinic.  Here we would see hospital follow up patients, patients with chronic medical conditions that needed follow up, referrals, and well baby visits (for an initial hospital follow up and anticipatory guidance after being born-- usually were ~1-3 weeks old and if they were doing well, they would not require any further visits, just routine follow up with the health centers to get their immunizations).  The clinic would be a steady flow and there were plenty of patients to be seen.  One of the doctors that I had worked with the day before in the ward would be there with me seeing patients (again, a great resource when you need to figure out how to do a referral, navigate the healthcare system here).  Dr Ramos would also be there seeing new patients himself.  The day would finish once we saw all of the patients that had been there waiting (typically mid afternoon).  Annotto bay was ~45min-1 hr drive.

Port Antonio
I was actually only here on one Friday (as the first week, I had spent an extra day at Port Maria due to transportation arrangements).  Port Antonio is ~1hr40-2hr drive.  One of the administrators from the hospital drives you both ways.  I spent the morning here doing inpatient (seeing the 11 inpatient patients--bronchospasm, rule out sepsis, 2 social cases/holds, a burn patient, dehydration/GE), then in the afternoon saw ~10 outpatients.  The outpatient area was a little further away from the A&E so it was a little further to go to find someone to help you arrange a referral/further care for a patient.  The benefit was that my husband, who is also a physician, was here with me for the second week and he could run up to find what we needed for someone while I kept getting a history, charting, examining a patient.  Again, Port Antonio had a good patient volume.  Seeing patients in the afternoon there was a slight disadvantage because by the lab was then closed so there was no way to send someone for lab results and then have them wait for the results so I could see them before the end of the day.  There were a couple patients that I sent for labs and then had to just have them make the next available appointment in the clinic to follow up.  It was definitely a busy day there though! The people were very patient even though they had been waiting since the early morning to be seen.

The Resort Highlights:
We did the snorkel trip out to the reef and enjoyed getting to see some fish-- not as much quantity wise (we didn't see schools of the same species), but we saw plenty of colorful different fish.
The food is really good with a great amount of variety.  We enjoyed eating at Eight Rivers, which was probably our favorite.  We spent a lot of time eating at The Patio and had some great pasta and snapper.  The staff is really friendly and the service is great!  Everyone in the restaurants, working at the bars, the entertainment team was very friendly and nice!  I have heard great things about the steel drum band that plays on Wednesday nights, but unfortunately we missed it!  Monday nights is a dinner buffet beach party which was really nice as well!
We spent a lot of our down time enjoying some amazing weather on the beach and swimming.  The weather was a little up and down the first week with some rain, but the rain here usually doesn't last long.  A lot of times it will rain during, the night or early morning hours, but by the time you are leaving to go get some breakfast-- it is all sunshine.
We would fill up the couples resort water bottle with ice water for the day to bring with us and brought little sandwich bags and would pack some pastries, cereal or fruit from the breakfast buffet to snack on for lunch at the clinics.

Some helpful things that I learned:

Asthma/Bronchospasm:  They do have spacers available at private pharmacies but the patients do have to pay for them.  I had not really thought about how nebulizer machines wouldn't be as readily available.  One of the doctors mentioned that she sometimes tells families to do a makeshift spacer if they can't afford to buy them by having them put an inhaler into the bottom of a paper/styrofoam  and then hold the open part of the cup up to their mouths.

Eczema/Dry Skin (especially in babies):  In Jamaica many families will put chemicals/potential irritants into the bath water (which I initially didn't know to ask about).  These things include baking soda, blue (which is like a laundry detergent), etc.  They also will often bathe the baby in cold water and frequently will use wet wipes on the babies faces.  I found this information helpful so that I could tell families to avoid these things.  They do carry emulsifying soaps which are mild and unscented here which is what Dr. Ramos told me to recommend to families.

Neonatal conjunctivitis:  I was interested to find out that the vast majority of pregnant women with vaginal discharge do not get tested/treated with antibiotics.  It seems that because of this there is more concern for chlamydia/gonorrhea due to the fact that so many cases go untreated in the mothers.

Sepsis in infants:  Blood cultures aren't as readily accessible down here so they rely on the clinical status of the patient for treatment.  Many babies will be admitted for concern for sepsis and then receive a total of 3, 5, or 7 days of antibiotics depending on how they do clinically.

We had a great experience, both at the resort and at the hospitals.  It was a wonderful educational experience, and we hope that we were able to help some of the children in Jamaica!  The people here were all very friendly and the patients and their families were appreciative! 

Sunday, September 9, 2012

Week 1

Hi Issa blog family!
Week 1 was a very great learning experience. Port Maria was the busiest of the 3 clinics/hospitals.
There were a lot of sick visits during my 2 days at Port Maris, there seems to be a viral illness going around, causing high fevers, uri, and h/a. One boy who was 13yo had h/a, fever and nucchal rigidity on exam and while my gut feeling was that he probably had a viral meningitis, I couldnt be 100% sure so I walked him and his mother over to the ED dept where I was able to draw labs, send off a blood culture, attempt a spinal tap (which was unsuccessful because there were no spinal needles available, I was using 21g angiocaths); but he was admitted and would receive IV ceftriaxone. He will probably be home by the time I go back next week.

Annotto Bay reminds me most of home; Dr Ramos is an excellent Pediatric clinician and functions as a ward attending; he had 2 pediatric residents and I made a 3rd as I pre-rounded on a few patients as well. Once Dr. Ramos arrives we rounded on the patients with him and he does sit down rounds and PIMPs the residents. One case I took care of was an infant with indirect hyperbilirubinemia, likely 2/2 ABO incompatability; he was on phototherapy however I was not able to discern whether he was getting high intensity; one of his treatments was phenobarb, initially i thought is he withdrawing froms drugs because this is a setting i see phenobarb used, but dr. Ramos explained to me that he was on it because phenobarb aids in liver maturation (this baby was 1wk premature as well). That day I also learned to do a femoral arterial stick! The second day is a well baby clinic; most of the infants born at the hospital get seen at 2wks of age; if there is nothing concerning on exam they are d/c from Anotto Bay clinic and f/u at a private doctor or the various health centers in the parish they live in. I saw an infant with ring worm to the forehead and mother's lesion was on the R forearm; so I had to treat both with topical meds; there was another infant with an ear skin tag; where I am being trained we routinely do not get RUS as majority are wnl; however I confirmed what was standard of care with one of the residents and they do routine RUS so I gave the mother a lab slip to get it done when she could (she will be paying out of pocket ~10-20,000 Jamaican dollars).
Lastly coming home to couples resort is a real treat; for the real authentic jamaican food definitely the monday night beach party is where it is. Also personal trainer Alfred is really great and will customize a work out plan for you!
Till next week; I am going to read up on tinea infections and meconium aspiration syndrome.
~K. Godfrey, MD

Saturday, September 1, 2012

Day 1: First day was on a Friday- the day you go to Port Antonio hospital/clinic, which is in the parish of Portland. The ride was very scenic, and while the roads were winding they were very pristine; coming from the Bronx, NY it was nice not having to go over any potholes!
I totally forgot to bring my camera, however next friday I will so that I can catch some pics of the livestock hanging on the road sides; the local pple selling their produce (ackee, bananas, guineps) in addition to getting a great shot of the houses espetially the ones that resemble mini-hotels...I even think I saw one that was in the shape of a ship..Ill be sure to post of pic of that to convince myself!

Anyway; the hospital at Port Antonia has 2 stories, with multiple areas. The pediatric ward is humble, 1 large room for all the patients and directly across is the playroom/sitting area for families that come to visit their children. I worked most of the day in the outpatient wing; there I was in an airconditioned room...was very grateful for that, as I completely forgot I am in Jamaica and brought a lot of polyester tops rather than cotton (lol). The room is partitioned by a curtain, beyond the curtain is the examining table.
The room had hand snaitizer, soap, a sink to wash hands; papertowels and tongue depressors.
All I really needed to bring was my doctoring tools; and maybe my Harriet and Lane.

The pharmacy is on the compound, I asked the pharmacist for a formulary; which was very handy as I was able to pick out the meds I would likely prescribe before seeing patients. So when I did prescribe something, I just placed it on provided Rx pads and patients were able to get what I prescribed w/o a hitch!

Overall the staff is helpful and pleasant to work with...shot out to Nurse Burks! she worked closely with me triaging patients and obtaining vitals.

The staff here also wanted me to discuss some topics, I did 2 of 6 so far. It was well received and interactive. We talked about Bronchiolitis and Fever in baby (0-60days old); overall they manage these patients well but do to some limited resources may not be able to do everything recommended i.e. urine culture/blood culture/csf culture or spinal tap may not be performed on an infant in that age ranges 2/2 cultures going all the way to Kingston (4+ hrs away) and not returning in they just treat empirically with amp and gent. Or rather than treating initially with amoxicillin for an AOM, they jump right to Augmentin....
That's all for now; Will see how the other two clinics are.
Ciao! going to enjoy a glassbottom boat ride.

Monday, August 27, 2012

Pediatric Resident

Excited about the trip; hope to learn a great deal!

Sunday, May 20, 2012

Goodbye..what a phenomenal two weeks!

Hello...well I am back home stateside. Yesterday I said goodbye...for now to Jamaica. All I can say it was a wonderful 2.5 weeks. It was much more than I could have ever expected. As someone said it was well balanced....fulfilling work by day and peace, beauty and serenity by night. I think the best way to chronicle my experience is to do it by section….
1st impression:
 Well I have to say my first day began at Antonio Bay and was I in for a shock. My family is Jamaican and I have visited Jamaica many times since I was an infant and for some reason I do not think of Jamaica as a 3rd world country. However I realized how much it is a 3rd world country when I walked into the pediatric ward at Antonio bay. First all the babies and children are in one section…no separation for preemies (they would be in a controlled environment like a NICU here in the states) and regular sick children. The cribs were not of the best condition and were of different shapes and sizes. I guess you just have to see it to understand. On my way to the pediatric ward, I passed the maternity, women’s and men’s ward, and they were unlike anything I’ve ever seen. All the patients were in these huge room/wards with up to 20 patients in these wards. The 1st days at Port Maria and Annotto Bay was pretty much the same.
Honestly I felt proud to be working with Jamaican children. I felt like I was giving back to a country of my ancestors. Most children came in with complaints of skin infections mostly eczema, scabies and fungal infections. There is A LOT of scabies. Not sure why...maybe it’s environmental…. Jamaica is a very lush, green island. And these kids came with chronic scabies infections. In some cases, due to scratching, they became super infected. I had to treat 2 kids with antibiotics due to super infection. In at least 2 cases, I could not identify the skin condition because I had never seen anything like them before.  In one instance I referred a 10 week old for a severe fungal infection to Bustamante for dermatology. There was nothing more I could offer.
If there is anything that frustrated me was the lack of readily available resources. You really had to work with what you had which wasn’t a lot in many cases. For example I had a child with probable pica. 1st thing I wanted to do was order a CBC to see if this child was anemic. But I knew that would be a waste because I would not get results quick enough and would probably lose the child to follow-up, so I just placed the child on MV with iron. And I guess I was a bit more aggressive with treatment than I would normally be because confirmatory tests were not easily available. I noticed this was done on the ward as well, when on rounds the GP told me he placed a child, who was admitted for bronchiolitis, on antibiotics because he was unsure if the patient would return for follow up i.e. a respiratory check. One child came into clinic with a questionable lung exam with some but really not impressive focal findings but in any case I placed him on antibiotics because I was unsure if he would come back and I couldn’t do any imaging. There was also a great deal of asthma, which for some unknown reason surprised me.
In terms of patient load, it ranged from say 8 kids to 15 or so. On one clinic day at Port Maria, I saw 20 patients during the morning session. In Jamaica, children are normally seen by a general practitioner not a pediatrician. Pediatricians are considered specialists, so if the patient guardian has a complaint, then they are referred to the Pediatrician if one is practicing that day.  In other instances the GP would treat the child.
What can I say…the ultimate in luxury. Couples lacked NOTHING. The accommodations were wonderful. The Issa doctors stay in a very roomy villa. We had separate entrances with our own bathroom. The living room and kitchen were shared spaces. Most time I stayed in my room and met up with the other doctor for meals or so. The staff were wonderful, kind and tended to my (and other guests) needs. If you are lying on the beach, there is a waiter there to take your drink order.  The food in each of the 4 restaurants is absolutely delicious.  I felt like I was dining in a 4 star restaurant every night. And since I am of Jamaican heritage, I was able to indulge in some of the islands traditional meals like ackee and saltfish, calloloo, and jerk chicken. Coming home to a place like this after a hard day’s work was perfect. It was just right. There are plenty of activities to partake in such as snorkeling, windsailing, glass bottom boating, shopping trips and trips to Dunns River.
I just have to say, this was one of the most memorable experiences in my medical career. This is the main reason why I switched careers from banking to medicine – to make a real difference in the lives of the underserved whether it’s here in our country or in other parts of the world. I chose Jamaica because it’s the land of my mother and father..and I still have many relatives that lived there.  I felt like a real doctor! In just about all cases I had to use my judgment without the assistance of a readily available preceptor. This is particularly helpful to me since in just about 3 months I will be entering the “real” world as a full fledge pediatrician. It did wonders for my confidence and gave me great experience. I wish more residence knew about this program.  It really offers the best of everything you would want in an overseas rotation.

Thank you Diane Pollard, the Issa Trust Foundation and Couples Resort for this extraordinary experience.

Randi B. Nelson MD

Saturday, March 24, 2012

Goodbye Jamaica

It is with a definite sense of sadness that I find our stay coming to an end. I regard it as having been a wonderful opportunity to have experienced another culture, practice pediatrics and get a taste of a tropical paradise in an all-inclusive resort.
The time was a nice blend of culture, work and enjoyment. I found it mind expanding not to be so dependent on technological medicine we have come to be relie upon, and to free ourselves from are obsession with the clock. Jamaicans are polite, relaxed and respectful, at least all that I have encountered on this trip. What they lack in material possessions is made up for their joy and laid-back life style.
Thanks are due to the Issa Trust and its president Diana Pollard for arranging this opportunity for me and my wife, Martha, to partake of this most beautiful island's culture.


Friday, March 23, 2012

It's a Wonderful World

This is my second week at the Edgehill School for Special Education in Port Maria. I am getting to know these bright eyed students better and learning their names, many are names I've never heard before. I taught the song "It's a Wonderful World" in American Sign Language. One of the teachers found the Louis Armstrong version on the computer and played it along with our singing and signing. That was very effective!  I am leaving my Sign Language book with the school.

Since there are 45 students of various abilities and ages, I modify these lessons accordingly. Paper and pencils are ALWAYS in short supply, and the drawing pads I brought were used up, so I bought more at the local book store.  Dry erase pens are also something which is consumed (dried up) and need replacing. I bought more, but that is also in need as is a copy machine (someday).

Sometimes, I use patterns to trace around. All the art work was displayed in an Art Corner. Most of it I had covered with Saran Wrap, but one day, there was a torrid of rain, some blowing sideways through the windows, and some of the artwork was ruined, but much survived and is still displayed. The students stand in front admiring their artwork and that is a thrill for me!!!

There is an ART CORNER now at the school.

1. tracing their hands with pencils and using watercolors to fill in ---taped together to make a big poster

2. used oil pastels (there was a set given but not used, since the teacher didn't seem to know how to use them---she appreciated learning---I  brought in samples of Hibiscus, fern leaves, Mousetail pods, grape and almond leaves. The students made lovely botanical art which I taped together in a poster.

3. used soft pastels to create still life--I brought in pineapple, papaya, apples, banana, and star fruit for the students to draw and fill in with the pastels. I taught them about how to see and draw the shadows that these fruits cast on paper.  These pictures were mounted and displayed.

4. used old magazines (which the activity director at the resort gave me) and cut out photos of various people doing jobs. These were glued on paper and the students filled in with markers "the rest of the story" This tied in with their Career Day at the school. The speakers who were scheduled didn't show up, perhaps due to the rain, so I was a speaker. I also taught a game to the whole school which seemed to be a hit. " name is......and I live in ........and I like........" It's a great game to teach thinking skills as well as geography.

5. I will be using watercolors and crayons to teach the concept of symmetry making butterfly pictures.

I think that I've enriched the lives of these young students as they have enriched my life, too!!

Thursday, March 22, 2012

Complications of TInea Capitus

On Monday and Tuesday this week, I was working in the clinic in Port Maria and saw two complications of tinea capitus . The first child I saw on Monday was referred in from another clinic for an I&D of a scalp swelling that was not getting better on oral antibiotics. I sent the child to the A&E for the procedure. When I returned Tuesday, I spoke to the Dr. Mighty of the A&E and she told me when they opened up the swelling several live maggots came out. This she said happens when tinea goes untreated and the necrotic tissue is a source for the maggots. They were treating the child with a power that is cidal to the maggots, in addition to Griseofulvin and shampoos. This was a new one for me.
The second case I saw on Tuesday. A child brought in by his aunt, who had custody of him for most of his life. She said he had scalp lesions for several weeks. When she removed the bandana covering his head, I saw large bald spots that were boggy and oozing. It was a kerion, an inflammatory reaction to tinea. In thirty five years of practice in America I could only recall only one or two cases. I was advised to admit him for oral Griseofulvin, Prednisone, and to have the social worker access his home life.

Both these cases gave me a new respect for possible complications of untreated tinea capitus.


Saturday, March 17, 2012

Our First Week
Well, we just finished  the first of our two week volunteer rotation here in Jamaica and it has been interesting,
educational, fun and at times tiring. Really, though, it has turned out much better than we could have hoped.
On the medical side, all of the clinics are a little different. Port Maria, where I spent Monday and Tuesday, was the most Spartan in
terms of facilities. Monday started off poorly when I was waiting in the lobby for a ride and after multiple phone call discovered no one knew I was to get picked up.
Dr Ramos interceded and put me in touch with the hospital administrator who then sent a driver. Even though I arrived about an hour and a half late, I was able to see all the
patients and leave at a reasonable hour. I met several of the hospital docs who were all friendly and happy to have me. They asked me to make an educational presentation next week, and I agreed
to give a talk next Monday on asthma, a subject I am quite familiar having championed it from my time at Kaiser -Permanente. I asked them to bring up a case on Tuesday as a spring board for a discussing of fluids and electrolytes.
Wednesday,  I was  in Annotto Bay on their Pediatric Unit. There Dr Ramos spent about three hours in a most didactic fashion reviewing with the residents the cases on the ward. There was a new nephrotic/nephritic,
a child with recurrent seizures and a baby with hypoglycemia among others. He is a great teacher and the process stirred memories of years ago when I was a resident physician. The next day, I was in the outpatient seeing children who had been recently discharged, either as newborns or with some other medical problem. The facilities were an improvement on Port Maria in that I had a real table to put my things and a
chair with wheels to sit in with an adjoining bathroom.
Friday I went to Port Antonio, a two hour drive. I was picked up by the hospital administrator, Patrick Campbell. We had a delightful conversation that spanned such topics and the economy, lifestyle and religion of Jamaica as contrasted to the USA. The time of the drive went by quickly and I was pleased that I did not suffer any car sickness like others had warned me about. In Port Antonio I saw a few children who were referred from local health centers for such conditions as poor growth, recurrent chest pain, etc. I had some free time and went to the A&E( their ER) and saw a few children with minor problems.
I will have to admit, staying here at the Couples Resort is a real treat. I am taking piano lessons at home and have been able to access the piano at the resort for some practicing every morning before going to work. When I return from work, on almost every day, I have taken a tennis lesson with the local pro. He is a wonderful teacher and was formerly #2 player in Jamaica. The food is great and there are activities every evening, though we tend to turn in early to be able to get enough rest to be prepared for the next day. Today, Saturday, Martha and I were off together and we went on a guided nature walk of the property and then a snorkeling trip to a local reef. It definitely has made us appreciate the beauty in the natural setting we find ourselves.
Now onto week #2 and we will see what new adventures we well encounter.

Martha's Blog:

My first week at the Edgehill School for Special Education, in Port Maria, formerly called the School of Hope, went well. There is a wonderful staff of patient, kind teachers. I have been working with each of the 3 classes (45 students) to teach some sign language, alphabet recognition, and some signs which might be helpful for the less verbal students. Each day, I presented art lessons using the art materials I brought with me from California: tempera paints, watercolors, fingerpaints, soft pastels, and colored marking pens. Since the director of the school told me that there will be an art contest in a few weeks, I've mounted some of their finished works for display. Working in with students to complete a project, build creativity and self esteem, has been part of my goal. Luckily, I brought some plastic aprons to protect their uniforms since some of these projects have been a bit messy.  I have taught some art theory, too, using a color wheel and some techniques for using the materials. I have found these wonderful students have been instilled with the admirable qualities of showing respect, taking care of materials, and cleaning up after themselves. Fortunately, Diane arranged for  a wonderful driver for pick ups at the Couples Resort and drop offs at the school . He has also gone with me to help me find additional supplies. The school has some art supplies, but they are in short supply of paper and other school supplies, and have no copy machine.  I'm looking forward to next week at the school.

Sunday, March 11, 2012

Just Arrived

I thought we should introduce ourselves as the newest, but oldest in age, ISSA volunteers. My name is Richard Pastcan. I am a semi-retired pediatrician, having worked for Kaiser-Permanente in Northern California for 32 years. For the past three years I have been at a community health clinic serving mostly low income and Spanish speakers as a general pediatrician. So unlike the other volunteers who were in their last year of training,  I represent the other end of the career spectrum. I am anxious to experience a different form of health care in a different culture.
I am fortunate to have my wife here with me to share in this experience. Martha is a retired teacher of the deaf, and the ISSA program director Diana Pollard has connected here to a special ed school in Port Maria. Martha has come with a duffle bag full of art supplies and hopefully this will help to engage the students.
We arrive at the Couples Resort two days ago and it is really as nice as all the prior blogs have described. The setting is a tropical paradise, the food is great and the staff is most helpful. It was good to come a few days early to get used to all of this, and get to know the surroundings a little. Yesterday we went to Dunn's River Falls which was a really memorable experience walking up a picturesque waterfall. I got to take a tennis lesson in the afternoon and this also made me very happy.
We'll let you know how are first days work .

Richard and Martha

Tuesday, March 6, 2012

Another Interesting Case, Though a Bit Sad....

Last week at Port Antonio Peds clinic we were referred a patient from the health center. He was a 6 month old male who was referred to us for concerns of hypotonia. Upon further history, we learned he was a term baby, growing and thriving, and mom had been concerned about his tone for quite some time. The nurse at the health center also noted some nystagmus at rest. On our exam, he was not dysmorphic, HEENT, CV, Lungs, Abd were normal, though neuro was not. He was hypotonic diffusely, though normal muscle bulk. He was also hyporeflexic in all major muscle groups. His Fontanelles were still open, and maybe a bit on the wide side. His eye exam was significant for horizontal nystagmus at rest, and exagerated with eye movement. His pupils responded to light and he blinked to light, though did not focus or react to any visual stimuli.
We had many concerns about this baby, specifically his tone and whether or not he could see, and he obviously needed some further testing, thought where to start? Of course the cell phone server was being worked on that day, so we were limited with our contacts, though I (Chris) did manage to get in touch with Dr. Judy Tapper in Kingston. She agreed that the baby needed to be seen, and didn't want to suggest any tests until she saw the patient. Mom was very concerned about cost and had very limited resources. Dr. Tapper was very friendly and helpful, though explained that she was the only pediatric neurologist in the country of Jamaica, and therefore was very busy. If the patient wanted to go to the free clinic at Bustamante Children's Hospital, there was a 6-9 month waiting list. She could go to Dr. Tapper's private office, though would have to pay out of pocket for the visit (About $9500 Jamaican Dollars - roughly about $120 US) I explained all this to mom, and she understood, I told her to make the appointment at the free clinic, though stressed that if she could go to the private clinic, this would be preferred. As this was not an emergency and I had no true reason to admit the patient, these were the options. Mom understood and said she would try to figure out a way to find the money, and would make the appointment at BCH in the meantime, and would follow monthly at Peds clinic until further testing was done.
This case was interesting, though made us a bit sad, as if this boy and mom had more resources, she may get some answers a bit sooner. Hopefully it all works out and mom gets the answers and help that she needs, though at this point I'm not sure I'll ever know how it turns out....

Sunday, February 26, 2012

Weird Rash - Any Thoughts?

4 month old male who was discharged from the ward 2 weeks prior for resolved bronchiolitis. On the day prior to discharge, he developed a rash on his left leg. They were told it was probably a reaction to one of the medications (he was on Azithro and Augmentin) and gave him some diphenhydramine which did not change. The rash then spread to other parts of his body like his other leg (and soles of feet), both arms, left shoulder, and abdomen. The rash was obviously pruritic, though he was otherwise comfortable and non-toxic. The rash appeared to be in clusters, though didn't seem to follow a dermatome or other pattern that we could identify. The lesions were mixes of papules and vesicles vs pustules? Hard to really say what it was. Mom said it seemed to be spreading slowly over the past two weeks. Any thoughts???? We were between scabies and varicella, though we're sold on either. Our plan was to treat for scabies and have her follow in a week, or sooner if it got worse.

Half Way Point

Well, hard to believe we've already been here two weeks and our trip is half way over. The sites are becoming more familiar, the accents are becoming clearer, and we are starting to feel the exhaustion. Though,having said that, we are learning so much about the people, the healthcare system, and the island it is just great! We wanted to hi-light a few of the cases that we thought were interesting over the past week.

1. Crush injury to the finger. Stephanie tried to save the finger tip of a 2 year old girl who got crushed by a bucket. I (Chris) held the best I could. What we wouldn't have given for a papoose and a digital block! Though all in all, turned out ok, and mom returned the following day for an Xray and wound check!

2. Testicular swelling. I (Chris) saw a 3 year old boy with 3 days of unilateral testicular swelling that mom thought was occasionally painful. His exam was non-tender, though definite swelling and firmness on the right. Testicles are on my list of "don't mess around", so I knew he needed an ultrasound - though where to send him? Port Maria does not have US, and Annotto bay likely didn't do scrotal US. The NP told me just to send them to a private ultrasound place and they would bring the results, though who knows how long it would take - and if it was positive, then what? So, I grabbed the yellow pages and called Bustamonte Children's Hospital in Kingston, ID'd myself as a doctor, and asked to speak to someone in Urology. Within a minute, I was transferred to the head of urology and surgery Dr. Abel, and he couldn't have been nicer. He agreed to see the patient the following morning and do an Ultrasound there, and mom was happy to take her son to Kingston. Glad this one worked out!

3. An interesting rash (see next post)

4. Chronic Diseases: I (Chris) saw a lot of patients for chronic disease follow up. While I relish at the opportunity to see asthmatics and give them education and stress the importance of the "brown pump" (QVar) and "blue pump" (Ventolin), there were a few that I wasn't as comfortable with. I saw multiple patients with Sickle Cell Anemia for their check up, they looked great and I just continued their prophylactic antibiotics and folic acid. I also saw a rheumatic heart disease check up, though he was in relatively great health, I was releived when mom told me he was going to see cardiology next month!

5. Holy Murmur! Stephanie and I saw a child (12 year old male) in the A&E at Port Antonio for follow up labs for syncope and Mom said, "oh yeah, he's a heart patient". Gulp. It sounded like his syncope 3 weeks ago was likely due to some dehydration and vasovagal activity, though we needed to know more about his heart. She said he had "a hole" in his heart, was seen in Kingston as a young child, and actually went to Richmond, Virginia for evaluation 4 years ago. Mom said they didn't do an operation, and she was never really told what kind of "hole" it was. Hmmm.. His exam was impressive, with a true 6/6 holosystolic murmur - yes, we didn't need a stethoscope. We assumed he had a VSD, and as there were no signs of failure and he was doing great otherwise, we thought it best that they reconnect with Cardio in Kingston and mom agreed.
We also stressed the importance of follow up and discussed signs of heart failure.

Until next time!
Peace Mon!

Dr. Clare Hack reflects on her experience!

“The opportunity of to volunteer with the Issa Trust Foundation in Jamaica was invaluable.
As a physician working in an environment with limited resources, I learned to become more reliant and confident in my clinical skills, and really challenged to order laboratory or r imaging studies which are only absolutely necessary. I developed the utmost respect for the physicians who work in Jamaica, who every day work so hard to treat children without medical equipment we take for granted, such as CT scans, blood tests, blood gasses, cultures, and simple things like growth charts, which now seem like luxuries. Working in a country side by side with natives of
the country is an amazing to learn about a culture and a people. It is fascinating to learn about the healthcare system and the medical training system in another country. This organization is unique in that volunteers are provided with 5-star accommodations at an all inclusive resort, and volunteers have full access to all of the activities at the resort, including scuba diving, horseback riding, water skiing, amazing meals. It is an amazing opportunity from which all pediatricians would benefit.”

Tuesday, February 21, 2012

Ophthalmia Neonatorum or Neonatal Conjunctivitis

In follow up per Dr. Stephanie's blog, Dr. Ramos in Jamaica shares the following information:

Our recommend treatment for Ophthalmia Neonatorum or Neonatal Conjuctivitis does not differ from what is recommended and practiced elsewhere including many Pediatric hospitals
in North America.

Providing that the suspected etiology is infectious, then "triple antibiotic therapy" is
recommended. This consists of:

Topical: Tetracycline
Eye Ointment 1% for 7 days
Oral: Erythromycin,
50mg/kg/day (divided q 6-8 h) for 2-3 weeks.
Paraenteral: Ceftriaxone
50m/kg/ single dose (maximum dose 125mg).

Neonates treated as outpatients should be reviewed within 2 weeks.

Based on my experience (over 10 years) using this "triple antibiotic therapy", the vast majority of cases (>95%) will resolve.

We do not routinely recommend admission, unless there is an indication for it,

- Signs of systemic involvement (hyper, hypo or unstable body temperature, vomiting, coughing, sick looking baby, etc)
- Severe ocular signs (risk for intraocular complications)
- Concerns about treatment compliance or proper follow up.

If the baby is suspected to have a systemic sepsis in addition to the above outlined treatment regimen, we recommend a combination of Penicillin/ Aminoglycoside for at least 7 days or
until cultures reports are available.

It is to be remembered that cohorts differs from country to country, even from state to
state; therefore we must be aware of this when we approach a population of a different background than the one we are used to attend. Causative agents prevalences, popular practices, and socio-economic status all might also influence the way we approach these conditions.

Saturday, February 18, 2012

A Day In Port Antonio

Yesterday we went to Port Antonio Hospital. This hospital was in Portland Parish, about a 2 hour drive through winding, hilly, jungle roads from our hotel. When we arrived (thanks to our very polite ride and hospital administrator, Mr. Campbell), we were warmly welcomed and put to work. We tried to start in the Peds ward, though the docs had already rounded for the day, so we went to the outpatient clinic.
In the Jamaica, Pediatrics is considered a subspecialty so we had a lot of patients that were referred to us from general practitioners. Again, we saw lots of rashes, URI's, and scalp infections. We also saw two patients that we felt needed referral to ENT. One was a 2 year old male with language delay likely secondary to his tongue tie that was never corrected, and one 3 year old female with significant tonsillar hypertrophy and obstructive sleep apnea. Luckily (after a few phone calls and some very helpful nurses) we found out that there was an ENT clinic in Kingston at Bustamonte Children's Hospital every Monday - in luck! We filled out referral forms and the parent's seemed happy that something was hopefully going to be done.
After the Clinic and a quick lunch (we're getting really good at making English Muffin sandwiches at the breakfast bar and stowing them), we went to the A&E to help out. We saw a mixture of patients, but a few stood out. We saw a 5 day old male that had some eye discharge, his eye looked fine and just had some drainage dried on his face. We thought this was maybe some lacrimal duct stenosis that was very normal, or maybe a very superficial infection, regardless our plan was some warm compresses and antibiotic eye drops. Though when we ran this by the attending doc, he said that he would admit this patient for 3 days of IV ceftriaxone, and erythromycin, tetracycline and neomycin eye drops. He could tell I looked surprised, and I said that that wasn't standard practice in the states, and Ceftriaxone isn't approved for a baby his age. At first he acknowledged my plan, but in the end he wanted to be "safe, rather than sorry" and admitted the patient. I was glad he entertained my input for a bit, but in the end it was his decision. Any thoughts about this from other docs that have been here and treated Opthalmia Neonatorum - they do get "eyes and thighs" in the deliver room.
Another patient we saw was a teenage girl with syncope, and after a good H&P we felt that this was orthostatic changes due to dehydration and she probably just needed some fluids. We told the nurse that we wanted to give her some fluids, and she handed me a glove (for a tourniquet) a cotton ball soaked in alcohol, and an IV cannula (one very different from the IV's in the sates). Stephanie searched for a vein while i primed the tubes, and thankfully Stephanie got the IV in one try and we made it work! While this may seem like a small feat, we are so spoiled with our awesome nurses at Akron Children's, we were both holding our breath!

Thursday, February 16, 2012

Our First "Oh Crap" Moment...

Yesterday we went to the Annotto Bay Health Center, an outpatient clinic in St. Mary’s Parish that is peacefully located on the water. Although the staff did not know we were coming, they were very welcoming and we knew we would be of use as there were rows of Moms and Children already lined up. Again, we saw a mix of URIs, rashes, Tinea, and constipation, but there was one patient that made us both skip a heartbeat, if only for a minute.

A mom was sent over to us with her 3 month baby from the nurse. She was quiet, though polite. She said that after her baby was born, he had to be admitted for a few days because he was breathing fast. The breathing was improved, though mom reports that he had a chest x-ray and EKG that per mom “showed that one side of his heart was bigger than the other” - cue Oh Crap! She was referred for an echocardiogram, though she could not afford it, and was subsequently referred to a cardiologist in Kingston that had an available appointment in September (7 months from now!). Upon further history, the baby was doing well, feeding and thriving (with occasional sweats), no pallor or cyanosis, and developmentally appropriate. His exam did reveal a very soft mid-systolic murmur at the apex and LLSB, though no signs of heart failure. Our portable pulse ox (Thank God and Dr. Gunkleman from Akron) showed sats of 96%. We were reassured by our findings and planned to look up the Xray and EKG tomorrow when we go to the hospital that the tests were performed. Our thoughts were that this baby was probably fine and maybe had a small VSD, and his EKG probably was just RVH (cue Dr. Bockoven, “RVH in a newborn is normal!” mantra). We told mom that we would check on all this and for her to follow up with us in 1-2 weeks, and to keep her appointment with cardiology in September. In the end we were much more comfortable, but what a scary chief complaint!!

Monday, February 13, 2012

Day 1 at Porto Maria for Stephanie and Chris

Greetings from Jamaica! Let’s start with introducing ourselves. We are Chris and Stephanie, 3rd
year pediatric residents from Akron Children’s Hospital in Akron, OH. We are so excited to be starting our time
with Issa Trust Foundation, and sharing our experiences with the readers of
this blog. Before we get into the clinical
aspects of our trip, let’s first touch on the AMAZING accommodations at Couples
Tower Isle. The staff here, along with
Diane Pollard, have truly made us feel welcome and have made this a relatively
seamless start to our month.
was our first day at Porto Maria Medical Center. The center is very busy, having inpatient
wards (adult, maternity, and pediatrics), a busy A&E (Accident and
Emergency Room), a busy walk-in health clinic, and a pharmacy. We were warmly greeted by the staff, nurses,
and other physicians there and quickly got to work. We split up right away, with Chris working in
the Outpatient Clinic and Stephanie in the A&E.
At the outpatient clinic, I (Chris)
saw a lot of general pediatrics issues. Main problems I encountered were Tinea
Capitis, other various rashes, URI’s, and GI worms. After only a few patients, my training kicked in and I started to feel more comfortable with the system. Right now my biggest obstacle is learning
what resources are and are not available.
It’s all well and good that I know what the problem is and how to treat
it, though if the pharmacy doesn’t have the treatment I order , then what good
am I doing. As I get more familiar with
our resources, I feel that my nerves will be more settled. Thankfully the staff is very welcoming and
patient, and is very open to questions.
(Thanks to Dr. Hines for the dose of Albendazole – Stephanie had the
formulary in A&E!)
In the A&E, I (Stephanie) was
sent the less acute patients, the ones who did not require nebulized treatments
or IV fluids. As I sat there waiting for
the first patient to arrive, I felt the nerves building up. The first patient had complaints of a
possible seizure, which I am normally comfortable with, but found myself having
a difficult time since I did not what resources were available for testing or
work up. After I had a few patients come in with URI
and asthma complaints I started to get the hang of things and felt more
comfortable. Dr. Facey in the A&E was a great resource
to me, especially when I wasn’t sure what to do with Ventolin Elixir or xray
turn around time. Deworming was a big
complaint which I fully embraced and prescribed mebendazole. The parents seem open to education,
especially on asthma. I even filled out
an asthma action plan (which would make Chris, our future pulmonologist,
Our first day is over, we are
feeling less nervous, but still getting comfortable with the resources. We can’t wait to see what the rest of the
week brings. We will be blogging again
soon! Ya mon!

Friday, February 3, 2012

My last blog . . . Last day in Jamaica, for now anyway. Bittersweet. I miss home, but have had such a rich and rewarding experience here that it will be hard to leave in the morning!

It has been challenging at times, and looking back it seems that the first and last weeks were the toughest. The first week, of course, because I was getting used to how to treat patients in this medical system. The last partly because I was, by that time, feeling homesick. The other difficulty was brought on by a discussion I had the end of the week prior with Dr. Ramos and I had some realizations about things I had been experiencing that for a while made me feel somewhat depressed. I had grown used to patients and their parents answering everything I said with "Yes Miss." I tried my best to give education and explanations at the end of each visit and always ended with, "Do you have any questions?" Very rarely would anyone actually ask a question, and most times they would respond with a little giggle or chuckle, followed by "No." I told this to Dr. Ramos, and he replied, "Well how can they ask a question when they didn't understand anything you just said." Excellent point. Even at home, at times it is difficult to explain to a parent what is going on with their child in terms they fully understand, trying to find the words in lay terms while trying to provide necessary education. But here in Jamaica, one also has to deal with a language barrier. Even though I have gotten better at understanding the mix of usually broken English and Patwa that most people speak, I also ask them when I don't understand. Could they repeat, or tell me in a different way. But rarely would a parent ask me to do the same. I shouldn't have assumed they could understand my English. I came to realize that just because they did not have questions or nodded their heads and said, "Yes Miss," in a lot of cases it probably had nothing to do with whether they actually understood or not. Here what a doctor says goes, and most Jamaicans would never speak up to say they couldn't understand me. There is also the aspect that it seems that a lot of time the people just don't listen to what you say. I would be asked a question, and then as I proceeded to answer they would either start talking about something else, or a few times get up to leave the office. Anyway, after I realized all this about 3 weeks into my time here, I felt a bit helpless, wondered how much good I had been doing besides just writing a prescription when needed. When a mother comes in with her baby worried because that baby is having reflux (that is not in need of medication), the whole key is helping her to understand what is happening to her baby and why and when it will get better. That is whole idea of reassurance for me, education is the biggest part of it, knowing what is "normal" and what is cause for concern. But after a couple days, I just accepted that this is part of learning and part of working in an unfamiliar culture. It has been an amazing learning opportunity. I hope I can take this experience and become a better listener and a better educator for all people. It has been a very important lesson for me.

Overall, I hope that this whole experience will make me a better clinician in all aspects, as well as improve my cultural competence. I am truly grateful for the opportunity!

I encourage other physicians and health professionals to take advantage of this opportunity as well. The Issa Trust Foundation has room for 2 physicians here all year round! It would so wonderful if there were always pediatrians here, a consistent presence to serve the children here so they receive appropriate follow-up and care. You will be challenged, you will have fun, and you will leave feeling rewarded. The accommodations here are out of this world! You will have a lot of time for fun and relaxation in return for all the hard work you do during the week. Please, take advantage of this exciting opportunity to become a better clinician while helping the children of St. Mary and Portland!

So a HUGE thank you to everyone at the Issa Trust Foundation, all the many physicians and nurses I had the pleasure of working with here in Jamaica, and to my home program for allowing me the time to have this experience! I plan on coming back soon . . .

Wednesday, February 1, 2012

Black Dressing

Dr. Arleen Haynes-Laing, a past volunteer coming to us from CHOP and is from Jamaica said that Black Dressing is a local poultice/wound dressing that's used for infected wounds. Can be bought in store (don't know) how it's made but it smells "tarry" and is black. Families swear it works well. Another name is used for this dressing is "Heal and Draw." It heals wound while it draws out the pus.

Sunday, January 29, 2012

I've just finished my 3rd week here in Jamaica, and it was the busiest yet! Post Maria had so many Pedi patients, I saw 30 on Tuesday, and even had to give 5 extra back to A&E! It was an exhausting week, but full of so much great learning and good challenges.

One thing I've had to get used to here is that I am always "Dr. Westman," not "Amy," at least at the hospital. I come from a laid back California Pediatrics program where I am on a first name basis with everyone in my program, from interns to attendings and administrators. But here in Jamaica, it is more formal. A doctor is always "Dr. . ." and a nurse is always "Nurse . . ." The other doctors and even the interns introduce themselves as "Dr . . ." and I've noticed that even when they drop the doctor part, others refer to them by their last name only.  So now I've grown used to introducing myself as Dr. Westman, but it still feels strangely formal!

Another things that just goes with the territory here, and I presume for all global health rotations or missions, is that you just need to relax and go with the flow. Things are not a tightly regimented and scheduled here as in America, but everything gets taken care of in the end. The patients show up at 8am and register first come, first serve, but will wait all day to be seen, no appointment times. You, as a volunteer here, will always have someone to drive you to and from the hospitals and clinics, but it may not be the same person and they may not pick you up at the expected time. But you will get there and back safely! The doctors mentioned in the orientation packets may not be around, but there is always someone there to help with any questions. Even if there aren't many clinic patients one day (my wide range has been from 2 to 30, but on average about 20), you can always find other ways to help out like seeing patients in A&E. Just go with the flow, and everything will work out. One of the big things I've learned in my time here!

One piece of advice for anyone else coming here to work, is to really brush up on your IV placement and blood drawing skills if its not one of your strongest areas. I have never really been very good at placing IVs in small children. While my home program of course has requirements and time built into our training so that we learn how to do this, there has never been much pressure to get really good at it, since there is always a nurse or phlebotomist to do these things for you. Since I don't naturally love putting in IVs like some other residents, I haven't perfected the skill. In Jamaica, however, the doctors draw all of the blood and place all the IVs, so I've actually gotten much better over these past few weeks by necessity! I was also surprised to learn, that the GPs here, although I knew they saw all ages, actually do some surgeries as well. One doctor at Port Maria said he will do "simple" procedures like appendectomies or inguinal hernia repairs himself, but prefers to only assist on more difficult operations like a biliary atresia repair. He has of course received specific training in surgery as part of his medical training, but I was impressed. At least I can do my own I&Ds and laceration repairs!

For my last comment this week, I wanted to mention every Jamaican's apparent love for and confidence in diphenhydramine, or DPH elixir as its called here. Anytime a child has a cold, the parents demand DPH elixir. When I ask if it helps, they will either say, "I don't know, you're the doctor," or they will admit that it isn't helping the child's cold symptoms, but they still ask for it. Many parents here really want you to give them a medicine for their child even if its just a virus, and are not as much into supportive care like bulb syringes and humidifiers, partly because they do not have access or the funds for such things. I have come to appreciate the usefulness of diphenhydramine at home, great for allergie reactions, nausea, and insomnia, but never though of using it for a cold! I do suppose it is safer than most "cold medicine" mixtures that many used to give their kids.

Oh, by the way, I'm still trying to find out what is actually in the "black dressing!" I know it is not as widely used any longer here in Jamaica, but I'm still curious. A google search didn't help very much, and I keep asking every doctor and nurse I come into contact with, but no one yet has been able to tell me what's in it! It just keeps me interested, but I think I might have to just let this one go!

Sunday, January 22, 2012

First 2 weeks!

To introduce myself, I am Amy Westman, pediatric resident from Kaiser Permanente in Oakland, California. I am now 2 weeks into my month long rotation here in Jamaica! I decided to come here for my global health rotation because a couple of residents from my program had already some here and had told me what a great experience it had been for them. Hi Thao and Chung!

I am having a great time here and learning a lot! What a 2 weeks it has been! Its been hard coming from working in the American medical system to working here in the Jamaican medical system, but it is getting easier everyday. I've had the opportunity to see many patients and work with many wonderful physicians here. Our goals as physicians both here in Jamaica and back in America are the same, to do what is best for our patients, we just get there in different ways sometimes.

My weeks begin at Port Maria Hospital in the clinic area. Here generally kids that have shown up for regular clinic that day get funneled to me, or are sent from A&E (the ED), lots of general complaints. The first patient the A&E doc sent me was a consult to rule out leishmaniasis. What do I know about leishmaniasis? I work in California! So I said, "Give me  a minute," got out my atlas of tropical diseases, and read up quickly. Then I was able to say with some certainty that the child did not have leishmaniasis. But that's how a lot of my experiences here have been, learning through doing and seeing. I have seen the typical childhood problems that I see so often at home: asthma, eczema, otitis, pharyngitis, and cellulitis. I have also seen things that I have never seen at home, but now have seen several times and feel confident in my diagnosis, such as miliaria crystallina. So many babies at their well checks have developed it here, and at first I wasn't sure what I was seeing, but after looking it up on the internet (at night after clinic - no wifi or computers there) and seeing it over and over again, I can now confidently tell parents what it is and offer reassurance.

I am also visiting Annotto Bay Hospital in the middle of my weeks. There I see patients and participate in ward rounds, as well as being in the pediatric clinic where I see kids with problems that are followed by the pediatrician there, Dr. Ramos, and the physicians working there with pediatric experience. More asthma, anemia, and some follow-ups post discharge from the hospital. On the inpatient side the majority of the patients I've seen have been neonates with suspected sepsis or risk factors. Since it is very difficult to get cultures here (they must be sent to Kingston and most of the time never make it there due to transportation problems or make it there too late to be useful for making treatment decisions), most babies with any suspicion, those who would bet a 48 hours rule out in the states, get a full 5 day course of IV antibiotics and then are sent home on orals.

On Fridays I make the 2+ hour ride (thanks meclizine!) to Port Anotonio Hospital in the parish of Portland, where I visit the wards and then go to clinic. Here they do not have a pediatrician at all, but the general physicians round on the patients on the ward.

In general, most physicians here have been very helpful in offering assistance with navigating the health system here. Where a specialist is available, what days they have clinic, etc. I always have a lot of questions!

There are so many interesting cultural things to be learned as well. I quickly heard about black dressing, which is tar based (but I'm still not sure of its other components), an all purpose salve for infections and the like. It took me a while to figure out what the mothers were talking about when they said the baby had "coal" (not sure how they spell it!) in his emesis or diarrhea, now I think they mean mucus. I ask my patient's parents a lot of questions about things like this as you can learn so much from them about attitudes toward health and nutrition and home remedies used.

When you have off time, which is every night and the weekends, it is wonderful to be at Tower Isle where you always have great food and entertainment, and can always relax on the beach and read a book, as I so often do after work. There are so many opportunities for trips outside the resort if you wish to join them. It has taken me a while to get used to people serving me everything and always asking me if I need anything here at the resort, but its a nice time to relax and enjoy you're time off. A sincere thanks to the Issa Trust Foundation and Couples for giving me this opportunity to come and serve the children of Jamaica and learn so much from the people and my patients here! It has been amazing thus far, and I am so looking forward to my next 2 weeks with the adventures and learning opportunities they present.

Stayed tuned .  .  .