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Tuesday, February 26, 2013

Hello from Jamaica!

My name is Drew Behunin and I am an Internal Medicine Resident at the University of Iowa.  It has been my great privilege to be the first Internal Medicine doctor to volunteer with the Issa Trust.  Honestly, I was quite nervous before starting.  The Issa Trust is a well established entity when it comes to the Pediatric world in Jamaica, but up until now has not been involved in promoting care for adults. I have been in country for just over 2 weeks and have to say that my experience has been unforgettable.

In Jamaica, most medical graduates begin practicing right after graduation without formal residency training.  Some pursue advanced training through the university and serve as consultants.  While the physicians I have worked with did not complete residency training, they do a commendable job at taking care of patients despite the limited resources available.  I see a lot of the same diagnoses that I would see in the United States, however their management is at times more difficult.  In the United States, any patient presenting to an Emergency Room is almost guaranteed to get at CT scan of the chest, abdomen, and pelvis followed by an MRI of the brain just for good measure! :)  Not so here in Jamaica.  Most advanced diagnostic tests including ultrasound, CT scans, echocardiograms, stress testing, spirometry, and even some basic laboratory studies are only available in the private sector.  While these tests are cheaper than they are in the States, they are often outside of the financial capability of the patients.

Hypertension seems to be running rampant among adults.  While many are getting appropriate treatment, I believe there is a greater population that have yet to be diagnosed.  I have spent the majority of my time working in the Accident and Emergency Department and have seen a lot of patients who present for other reasons and also happen to have blood pressures in the 190/100 range.  In these situations it is a no brainer to treat.  However, there are many who come with a blood pressure in the 140/90 range.  I refer these patients back to their local health center for repeat screening, however, there is no great way to relay this need to the health center nor guarantee the patient will follow through.  I am convinced that uncontrolled hypertension is contributing to the rising mortality from cardiovascular disease.  The majority of my time on the Medicine Wards at Anotto Bay Hospital is spent caring for patients suffering from stroke, heart failure, and the consequences of diabetes.  I was relieved to see that all of the major cardiovascular medications are readily available including ACE inhibitors, statins, and diuretics.  Through all of this I have learned to depend on my physical exam skills and clinical intuition, both of which are invaluable tools in the long run.
Hello from Jamaica~
We are loving our time in Jamaica. Here is a run down of a normal week as a pediatrician.

Monday and Tuesday are at Port Maria Hospital. It is about 30 minutes away and is very rewarding. I have been working in the A&E (Jamaican ER) and have loved it. I have a room in the back and all of the children 12 and under wait on benches to be seen. The pediatricians in Jamaica only see children under 12 years old once they are 12 they have to go to adult medicine. Also, there are not a lot of pediatricians at the hospitals that we visit and it is very rewarding to see the patients and be able to explain the diagnosis. I have seen multiple different illness but URI is the most common diagnosis. Because the patients wait so long to be seen (they can wait a full day to be seen at the A&E) they always want to go home with a script for medication in their hand. I do a lot of counseling on cough physiology and what viruses are. Many patients think they need antibiotics and the cough will get better. Most of the patients understand once I explain why they do not need an antibiotic. If a patient needs an antibiotic they usually don't get the prescription that day. The pharmacy only takes a certain number of scripts a day and once they have that number they won't fill any more scripts. The patient can go to a private pharmacy but they will have to pay for the medication and many patients don't have the money for the prescription. If a child needs antibiotics, steroids, or nebs then it is usually best if they get the first dose in the A&E that way if they don't get there script right away they have at least one dose.

Wednesday and Thursday are at Anotto Bay which is about 1 hour from the resort. Here there is a pediatrician named Dr. Ramos . The days that I have been at Anotto Bay I have been in clinic or in the A&E. The census has been low so I haven't done any inpatient medicine. The 1st and 3rd Thursday on the month are well baby checks. They get their weights checked at 4-6 weeks and if they are growing well they are discharged to be follow up with their local health clinic. I love the well baby check days. I find that the majority of the mothers breast feed and the babies gain weight well. For the babies that aren't growing as well formula is expensive. A drug rep from Enfamil found me and gave me 5 large samples that I have been giving out which always helps. At Anotto Bay there are pediatric residents and medical officers who have worked with children for years and are knowledgeable. I had to ask lots of questions on my first day as the medications they use in Jamaica are different from the ones I am used to. They also have different protocols and I found it helpful to ask about admission criteria, asthma protocol, and dehydration protocol. There was a cricket match that we got to watch one afternoon which was a lot of fun. Our driver had to transport a patient and was 3 hours late to pick us up (patient care always comes first. Thank heavens there was a cricket match to watch.)

Friday is at Port Antonio which is 2 hours away. I started in the wards then went to clinic then the A&E. I enjoyed getting to see some inpatient children. The clinic at Port Antonio is also wonderful. I have seen scabies in a 4 week old with FTT, constipation, viral induced asthma, seizure disorder, sickle cell, G6PD, fracture, ITP ect... The patients are referred to see a pediatrician on Friday (and I am the only pediatrician available.) Thankfully I feel comfortable with the complaints and treatments and the patients are happy to wait if they can be seen by a pediatrician.

Medicine is different in Jamaica than in the United States and one of the medical officers put it best by saying, "just do the best you can for the patient with the resources available." I have learned that the people will listen to your advise if you take the time to explain the diagnosis and treatment. Next week I will write about the wonderful Couples Tower Isle Resort.

Thursday, February 21, 2013

Hello to all from Jamaica!

Katie and I have been in the country for a little over a week and are absolutely loving it.  As you can expect it takes a little time to get acclimated to the way things are done here.  For those coming from a large university with an electronic medical record, all of the paper work comes as a little bit of a shock.  We have found that the handwriting of those that have come before us isn't always the best.  We try to keep our notes suscinct but legible in order to help those that come after us better treat the patients.  The people are the most appreciative and patient you will ever meet.  They line up early and wait patiently to be seen, although, in those cases where only reassurance is needed, they feel better if they have a script for something in hand.  At Port Maria and Port Antonio most of our work centers in the Accident and Emergency Department.  The days go by quickly and the work is fulfilling.  The great part about the end of the day is the adventurous ride home and the great food that awaits us at the resort!

Drew & Katie

Friday, February 15, 2013

the resort in January

I am writing this a little late..but better late than never :) I wrote about the medical part, now my recommendations about Jamaica and the resort.

Things to do:
#1. The steel drum band on Wednesdays is amazing, I went to see it twice. The second time they had a group of break dancers that were incredible!
#2 The acoustic artist that plays his guitar on the beach on Tuesday night is also amazing. It starts late but worth it
#3 We went biking in the mountains one Saturday using the Chukka was my favorite activity in Jamaica
#4. Climbing Dunns River is really fun and a short little free trip
#5  If you mix the light beer with Ting (the grapefruit juice) it makes an awesome little drink that tastes a little like Summer Shandy
#6  The Catameran ride is fun and worth the trip to get out into the ocean and swim a bit
#7  The spa treatments are excellent and worth the money
#8  They serve lattes and cappucino in the shop by the beach from 10-6
#9. Love their sorbet and ice cream
#10 Fridays are lobster day..take advantage of that :)

Friday, February 1, 2013

Jamaican January

Hi everyone! I wish I would have kept up with this as the weeks went by but I was having such a great time it was hard to sit down and write. Like the most recent entry I will try to cover each hospital I went to and the resort.

Annotto Bay:  This hospital is currently under reconstruction due to hurricane Sandy so the pediatric ward was located in the old administration section. I've seen pics of the new pediatric ward and it looks amazing! Hopefully by the time the next docs arrive they will have moved into the new section and will be again taking pediatric transfers from other hospitals. We only had about 5-8 inpatients at a time due to the limited space but I felt like the experience in the inpatient setting, directly working with the Jamaican pediatric specialists here was very helpful to me. Wednesdays I would show up around 9 am and pick a few patients to see and then we would round with Dr. Ramos and Dr. Fischer around 11 am. There are other general doctors covering the pediatric section available to answer any questions you have and divide up the patients with you. After rounds on Wednesdays I would often head over to A&E (ED) to see any pediatric patients they had there. By that time, there usually aren't too many children so I would head out around 2pm Wednesdays when there is a driver available. The administration is really helpful in finding someone to take you back so I would just ask for their help each day when I was ready.

Thursdays are clinic days at Annotto Bay. Sometimes there were 16 patients scheduled and sometimes 65. This is a pretty fast paced clinic and they would call the next patient up to see me as soon as the other patient walked out the door, so I found it helpful to jot down a few notes in the chart and do the rest of my charting at the end. I worked again with a general physician and sometimes Dr. Ramos so there is always someone available to answer questions regarding how to refer someone, how to write a script, what is available, etc.

The inpatient unit had a wide variety of types of patients, for example, I saw children with post strep glomerulonephritis, ill asthmatics, meconium aspiration syndrome infants, and osteomyolitis in a sickle cell kid to mention a few.

In clinic, we mostly saw children for asthma check ups and well baby checks. However every once in a while there would be a weird rash, or something more unusual. I actually saw a first time mother who likely had ectopic breast tissue with a nipple in her armpit that was lactating out of her armpit!!!

Port Maria:

At Port Maria, they would send me patients from A&E that they normally would either see in A&E or send to the clinic. The only physicians I had contact with here were the docs assigned to A&E that day. Make sure you let both the nurses in the back and in the front, AND the doc know you are there. They will clean the room for you and send you patients. You are kind of off in a corner outside of the ED, so if you need to ask questions or need more supplies it is more difficult. Try to anticipate what you will need at the beginning of the day and they will grab it for you. Especially because you can't leave your things in the room. I would grab my computer and bring it with me when I needed to go into the ED for something, and I never left the patients in the room when I wasn't there with my things. Mondays are pretty busy, I saw anywhere from 15-20 patients on Monday, Tuesdays were much more low key and I saw about 10. So, bring a good book on Tuesdays especially, because Steve (your driver to Port Maria) can't always bring you back when you are ready. He is usually there by 4pm, but I finished by 2 or 3 most days.

I saw more ED type patients here and often had to make a splint, read xrays on my own, and even admit people. The A&E physicans are willing to do anything you don't feel comfortable doing, you just need to tell them you can't or don't know how to do something and they will take care of it, but usually the patient has to wait much longer then. I had to refer a few people to orthopedics, which is in St. Anne's Bay (about 1 hour away), they can be seen the next day.

I also ran into problems with meds being available at this hospital that usually are available, such as prednisone, salambuterol, cephalexin etc. It helps to ask your patients to come back and let you know if something wasn't available. Some of them are willing to go into town and buy the meds, but those pharmacies close early also so if a child really needs something right away try to write for it in A&E. I would send children in to get neb treatments and prednisone before they could go home. You can usually get xrays within an hour and I would just ask the patients to come back with the film that day. Cultures get lost all the time, so I rarely ordered these...If I thought a kid looked classic strep I just gave them amox. I would never do that in the US but cultures take a month sometimes to get back here.

Port Antonio:

This was my favorite place to be. It is a really long drive, I was there 3 Fridays, but the drive is beautiful and felt I was the most useful at this hospital. I saw pediatric referral cases from the NP clinics so I would see some pretty interesting problems. Most of the time I just had to refer them to the children's hospital in Kingston but it was nice to know that they were seen quicker because I was there. I also would help out in the morning on the pediatric inpatient ward, discussing complicated cases with the general medicine doc. I could do some teaching and there were often complicated cases, such as an 11 yr old with hyperbilirubinemia and sick asthmatics. So my first 30 min-hour was spent on the inpatient ward, then I went to clinic and saw anywhere from 3-12 patients (mostly referrals or kids needing refills for asthma, seizure meds, etc), then I would go to A&E and help out with acute sick cases. I saw anywhere from 2-10 patients in A&E also. I left at 4pm each day, so it is also helpful to have a book along in case your case load is less for that day. Mr. Campbell, the hosptial administrator drives you there and back. He is really friendly and always on time.

I gave a presentation the last Friday I was there. I did a talk on acute abdominal pain in children and it went awesome because 10 people showed up including the surgeons and ob/gyn physician, Dr. Davis. We had a great discussion. I recommend bringing a powerpoint you have done before or something you have prepared ahead of time to present, as they really appreciate the presentations at this hospital. In the past, people have talked about bronchiolitis, vomiting and diarrhea, etc. Ok I am publishing this a little late, I left 2 weeks ago but hopefully this will still help. I will write about the resort next.