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Monday, March 25, 2013

Last day....

After a good nights rest and some medication both myself and Stephanie felt much better. It took awhile to get going on Friday but the Jamaica sunshine is a great motivator.We were unable to go to Port Antonio on Friday which made us both sad because we've seen so many great cases there and their need for Pediatricians is perhaps the greatest. Dr. Ramos only sees pediatric patients on Tuesdays and he has to limit the number to 15 given his other duties. Now that the community of Port Antonio is catching wind that we are present on Fridays the patients come in good number.

I have to say we took our last weekend by storm. We first decided to lay in the sun and relax as both of us had not felt well for the pat 24 hours but after watching everyone else on the resort participate in activities we were both itching to do something. We decided on snorkeling and had a blast. We saw tons of fish, my favorite were these amazing light blue ones that reminded me of Dori on 'Finding Nemo' and Stephanie loved the yellow fish with black stripes which she thought kind of resembled Nemo :) She was also lucky enough to see a sting ray! I was soooojealous!! We were pretty exhausted after this one little excursion so we returned to the room for some rest and nearly slept through our dinner reservations made over a week ago. But no worries, we rallied and got ready in no time. After can't pass up the amazing food here on Couples resorts.

Saturday we awoke to go train for scuba diving. We had been looking forward to this the entire trip but typically they only do classes on weekdays. We first did a swim test (you have no idea how hard 4 laps
in pool can be) and luckily we both passed! We then watched a 30 minute video about the equipment and safety instructions for scuba diving. Then we were off to the pool in our gear. We like to think we looked fashionable but our wet suits were a little awkward fitting to say the least. We practiced in the pool for about 45 minutes but unfortunately I had a cold and was unable to clear my ears at just 6 feet (the depth of the pool) and that's not safe for scuba diving. Steph and I had a blast practicing in the pool and our instructor was phenomenal. I guess I've just been loving up on too many sick Jamaican children in the A&E :) Since scuba was out and we were feeling adventurous we decided to go skiing behind the boat. We've both have been water skiing behind boats in the lake but never the ocean so we were beyond excited. It was late morning and the water was a little choppy but we both managed to get up twice and had a blast. Our boat driver Kenneth was so nice and knew exactly how to pull skiers out of the water.

 Later that afternoon we went on the Catamaran cruise (our 4th time...we know, a little excessive) but we love the crew and the peacefulness off being out on the ocean. Plus we met some great people this time who were spending their anniversary here and had some great conversation. The waves were a little crazy and Stephanie and I had a few scares sitting on the front of the boat (I lost my prized blue aviator sunglasses!!) but all in all it was a great time. I found myself in a back flipping competition off the boat with one of the staff, Odain, and I like to think I won. He was much more fearless than me though and his one foot back flip was a crowd pleaser. After returning back to the resort, we participated in a Reggae Dance class on the beach. I'm sure we provided great entertainment and a lot of laughing for those watching. We again had a great dinner and ended our night by skyping our fellow 2nd year residents. This weekend was our annual retreat and we were sad to miss it but we like to think we were there in spirit. After much laughing and telling them about our experiences here we hit the sack looking forward to our last weekend day on the resort.
We woke up Sunday and climbed Dunn's River. We had both done this before, Stephanie 6 years ago on a cruise and me on my honeymoon 4 years ago, but we were up for a 2nd trip. The sun was out and we again
were feeling adventurous. Our bus driver, Gary, had to be one of the funniest people I've ever encountered. He gave us a full tour of Jamaica on our way to the falls telling us about everything we passed from an Electric Store with the motto "stronger for longer" (you can imagine the jokes made) to the only radio station on this side of the island called 'Irie' which plays only reggae music. He then gave us a run down of the geography of Jamaica, explaining that we had passed through 4 parishes from the airport to the resort which resides in St. Mary (interesting fact is that Port Maria where we work Monday and Tuesday is the capital of St. Mary). We arrived at Dunn's River and after very strict instructions from Gary regarding vendors and video purchasing we were off. It was a great group of people from the resort and we had an absolute blast. Walking hand in hand with a bunch of strangers up a waterfall doesn't sound like the safest thing but we were taken care of by our guides and each other. From falling backwards into the water to going down a natural slide made in the rocks we were smiling the entire time. We don't have pictures because we forgot to bring a waterproof camera but it was beautiful and a great time overall! We got back to the resort and spent the rest of the afternoon relaxing in the sun and making tie-dye shirts!!! I was much more excited than Stephanie as tie-dying has long been a passion of mine, just playing, kind of.  We made late afternoon spa appointments for a facial and pedicure, both of which were wonderful and a must if you get time. By the end we were so relaxed and thankful for the much needed pampering. We then headed to dinner and like always the food was amazing. We also met this great couple who were on their 13th trip to this resort and had a son in his 2nd year of medical school!! We had great conversation with them and ended the dinner stuffed!


Today was our last full day in Jamaica and Stephanie and I both woke up sad. We pumped each other up at breakfast and reminded ourselves we were dedicated to returning. The children of Jamaica have a huge piece of our heart and the need for their care is immense. We spent the day at Port Maria, which is perhaps my favorite hospital because we see the most volume there and the nurses are phenomenal and extremely helpful. We learned from our driver this morning that Port Maria serves 66 communities and 8 surrounding towns. No wonder the volume is so great! We also learned that they have no ultrasound machine or tech in the entire hospital. You must be referred to St.Ann's which only accepts 2 patients a day. We are blessed to have so many resources in America, this trip has taught me never to take that for granted. Stephanie spent the day in A&E and myself in clinic but upon our arrival we were met by a concerned mother. I had seen her 3 year-old boy last Tuesday for an ear infection and possible right-sided inguinal hernia. Mom's description of a bulge while crying or coughing was consistent and on my exam I could appreciate a bulge during valsalva. I made a referral for pediatric surgery at St. Ann's which only holds clinic Tuesday and Thursday morning but mom had not gone. I also gave her instructions for seeking immediate medical treatment if the bulge became painful and constant, there was color change over the area, abdominal distention, or uncontrolled fever. She followed those instructions thankfully and today she explained that the bulge had been persistent for 2 days and he was now limping while he walked complaining of pain. Stephanie and I were absolutely concerned for incarceration and after our physical exam and a discussion with the A&E physician the plan was for immediate transfer to St.Ann's to be evaluated by surgery. What an eventful way to start the morning! Clinic continues to be busy here at Port Maria and I saw many skin infections (a kerion being a new one) and lots of colds and ear infections. I had an especially adorable 1 year-old who was intrigued by my stethoscope. Sadly his newly erupting teeth posed a great threat so I eventually had to take it back but not before some great pictures!

Stephanie was in the A&E and had another appendicitis scare! Once again the lab was down so she only had an abdominal X-ray to help her in addition to her physical exam. And guess what? Constipation strikes again. She also had a little girl brought in by her Aunt for breathing difficulties. On exam she was wheezing with crackles on the right lower base and her vitals on presentation revealed hypoxia. She was placed on oxygen immediately and given a breathing treatment. Unfortunately she didn't improve and was admitted to the hospital. She was treated with CTX and continued on oxygen with the admission diagnosis of bacterial pneumonia. Most of her labs and CXR will have to be done later since everything had closed down for the day.

Our last drive home from work was gorgeous like always. After you get out of the town of Port Maria it's just ocean for a few kilometers and it's breathtaking. Nothing can ever beat it.
Tonight were packing (and maybe crying) as we prepare to leave in the morning. We can't believe it's already over. We're planning on going to the beach party tonight followed by Margaritaville with the rest of the resort-goers :) it should be a great ending to a wonderful trip!

Fully blessed and sad to leave,

Sunday, March 24, 2013

Is it really almost over???

I can't believe that this experience is almost over.  Stevie and I have been so grateful for this month and are so sad when we realize its coming to an end. 

Wednesday and Thursday were our last days at Annotto Bay Hospital.  On Wednesday, we helped with patients on the pediatric ward.  Per usual, the morning was filled with interesting cases and great discussions led by Dr Ramos.  In the peds ward, there was a 1 day old 26 weeker who was doing surprisingly well.  At 900g the child was doing fabulous, maintaining good oxygen saturation without being intubated and maintaining his temp with an incubator that was duct taped closed!  We had an interesting talk on rounds about fluid management in neonates and the ways that things are done both at home and here.  Although we knew we were returning to Annotto Bay on Thursday, Stevie and I were both a little sad saying goodbye to the doctors we had worked with on the wards.  Dr Blake, Dr Yandav, Dr Fisher and Dr Ramos have all been fabulous to work with here in Jamaica and we hope that our paths cross again at some point!!


Wednesday afternoon Stevie and I had our first exposure to cricket as we watched a high school match.   Jamaicans take their cricket games very seriously!!  I was amazed at the number of people watching and the loud cheers when the home bowler hit the wicket!!

Thursday was a busy day at Annotto Bay!  Every other Thursday is well baby clinic where any infants born recently return for one follow up with hospital physicians.   After that visit, if they are doing well then they are just followed at the community health centers for immunizations.  When Stevie and I arrived there was a huge line of mothers holding their infants waiting to be seen.  We quickly got to work seeing the adorable newborns.  Fortunately, we did see many healthy newborns who were breast feeding and gaining weight wonderfully.  I also saw 2 patients with supernumerary digits.  Interestingly, when I mentioned removal one of the mothers told me she wanted the extra digits to grow--- she had also had supernumerary digits and was angry that her mother had hers removed.  Unfortunately, the extra fingers were already starting to turn purplish so I spent a great deal of time educating the mom about why they would need to be removed and referred her to surgery clinic.   I contemplated tying them off myself but due to lack of equipment and mom's reluctance I decided the surgery clinic would be a better idea!! 

I didn't want to forget to mention about some of the Jamaican culture we have learned about here.  Many of the babies seen here have "ascifnata" placed in their hair.  Stevie and I had no clue what we were looking at the first time we saw it!!  Finally one of the mom's explained that it's to keep colds away from the babies.  Apparently it doesn't work for older people though so don't go searching for ascifnata at the drug store next year during cold season!!  Also many of the babies have red bracelets on that look like hair bands.  The nurses told us that many of the mom's will get angry if you take these off the infants because they are placed there for protection and to ward off evil spirits also called dunny's.  No matter where you are in the world, culture will play a role in your medical care!! 

I also wanted to make sure that Stevie and I mentioned our gratitude for Dr Ramos.  Dr Ramos is one of a very small number of pediatric trained physicians here in Jamaica.  After clinic he spent a long time explaining the Jamaican medical training system to us, as well as how the hospitals function on a day to day basis.  He was also curious about the US system and details involving the residency program.  Dr Ramos is an excellent physician who constantly challenges you to push your knowledge base.  He is a great teaching physician who is wonderful for any learning physician to get to work with. 

Our afternoon at Annotto Bay actually brought us back to the peds wards where we helped Dr Yandav with procedures.  We were able to start IVs and perform femoral sticks for necessary labs.  In Jamaica, the physicians, not the nurses, start all IVs and perform all necessary labs.  Stevie and I both love procedures and wish we had more opportunities to perform basic procedures such as starting IVs at home.   This rotation has been a wonderful opportunity to help patients in need while also learning procedural skills from physicians who do these basic procedures day in and day out.  Although Dr Yandav disagrees, he is a wonderful teacher of procedures and Stevie and I both were successful at the procedures because of his advice!!  These hints are things I will continue to use while practicing in the US.  Another advantage to performing procedures in the afternoon was that Stevie and I were able to say goodbye to many of the fabulous nurses we have worked with on the wards!!  These people have huge hearts and we will miss them!

There is a soccer field right by the hospital.  Well a soccer field, cricket field, whatever you want to call it.  I love soccer and some Jamaican kids are amazing.  It's clear that they've grown up with a ball on their foot!!

Unfortunately, the ride situation home from Annotto Bay can be much more frustrating than at the other hospitals we work at so we are getting back to our resort way later than usual.  Stevie hasn't felt great today but we're hoping a relaxing ride home will help her feel better.  Keeping our fingers crossed that later on we'll be enjoying the great food and live music that we've become accustomed too.

Still feeling so blessed,

Wednesday, March 20, 2013

Only one week left!!

I can't believe this is our last full week, it's flown by. The drive to work is going to be hard to beat when we return home.

We started at Port Maria on Monday and we were busy! Stephanie was in clinic and saw many rashes, infected scabies being the most common.  After consulting with each other and the physicians we learned they treat with a combination of permethrin, augmentin, and mupirocin. Scabies is not that common in our setting at home and seeing it infected is even less common. Once again our physical exam skills are being sharpened. I spent the day in the A&E and felt overwhelmed with the number and variety of things I saw. At one point I had a little girl in the observation area receiving IVFs, 2 children in the lab followed by X-rays, and 5 patients waiting outside. It felt like home and my multi-tasking skills were at their best. Perhaps the most challenging but revealing case was an 8 yo male who presented with complaints of HA, sore throat, anorexia, emesis, and abdominal pain for 1-2 days. He was febrile to 102.4 on arrival and did not appear to feel well. After a detailed history I learned he lacked URI symptoms and combined with my physical exam of cervical lymphadenopathy and an erythematous oropharynx I was leaning towards the diagnosis of strep pharyngitis. I had one hold up though, his abdomen was extremely tender and he demonstrated guarding in the RLQ without rebound. Upon questioning he kept pointing to his umbilicus when I asked where it hurt the most. We all know appendicitis in a child can present atypically but pain that started near his umbilicus, tenderness in the RLQ, high fever, anorexia, and emesis seemed a little too classic to let him go with just a script for amoxicillin. So I started delving into more history asking mom about his bowel habits, desperately looking for another cause of abdominal pain. He did exhibit some signs of constipation so I decided a KUB and a CBC could help me make a decision. A KUB to look for constipation and even free air if he had ruptured his appendix (unlikely given his exam) and an elevated white count, again to help rule out appendicitis. We were unable to get the CBC but the KUB showed constipation!! By that time he was running around outside and I felt very comfortable sending him with a course of amoxicillin for pharyngitis and mineral oil for constipation. Long story for a simple diagnosis but it goes to show that you can't ignore classic signs of something you can't afford to miss, appendicitis. It also shows that constipation in children is painful! Always keep it in your differential!

Monday nights at the resort are "Beach nights" and they make this wonderful dinner and have appetizers and drinks and music outside. We haven't yet participated in this awesome party but we did stop by and sneak a few of the appetizers. Our plan is to enjoy it our last Monday here which is this one upcoming.

On Tuesday we returned to Port Maria and switched our roles, Steph in the A&E and myself in clinic. Unfortunately the clinic had no available rooms for me so Steph and I shared a room. It was a busy day but we made the small space work. We saw over 30 patients together! Along with our ability to be efficient, our physical exams were put to the test. For visualization, we saw classic tinea capitis, diaper dermatitis, and more scabies. For auscultation, we heard many variations of wheezing as we had to frequently assess asthmatics after breathing treatments. For palpation, we assessed for fluctuancy of skin abscesses and I'm fairly certain we felt the "sausage" mass associated with intussusception. Other physical exam findings to note were strabismus and ptosis. It was a great day overall filled with a  huge amount of learning potential we definitely capitalized on. Today also brought continuity which is amazing. Steph and I were able to follow up with our little boy who's finger was lacerated after a grease pan had fell on it last week. We repaired it and prescribed augmentin and mupirocin along with recommendations to keep the dressing clean and dry. But little boys being boys that dressing came back as dirty and wet as you could imagine. There was pus overlying the lac when we removed the dressing but I like to think our antibiotics and mupirocin helped keep the infection at bay. We ended the afternoon as we had done last Monday but Steph and I switched roles. I tightly held the sweet little boy in a chair while Stephanie removed the sutures and redressed it. It was quite the tear-filled experience for our little guy as he remembered the procedure room from last week but he still liked us afterwards. He's coming back next Monday and continuing on antibiotics.

When we got back to resort we were exhausted from a full day and we spent an hour sitting by the beach just talking about the patients we saw that day, reviewing their presentations, and running our plans by one another. It's such a blessing to have time after a long day to really process what you did. The opportunity to process rarely, if ever, comes when working at home. I think most residents would agree with me. By the time you're off work you're often so exhausted that the only thing you can do is eat dinner, shower, and go sleep as you prepare for the next day, especially as we've switched to shift work.  I cannot convey how wonderful it has been to just sit and talk with Stephanie about medicine. I know from our weekend adventures that medicine may seem to be the last thing on our mind as we return to the resort every evening but that's honestly not the case. We both feel like we learned so much here and are appreciative for the much need down time.

We concluded the night with an amazing dinner at 8 Rivers and we even got fancy for the occasion. The food was delicious and filling and the waiter was shocked when we turned down desert. We then went to the main dinning area to enjoy some live music and found ourselves out on the dance floor in no time. From 'We are Family' to 'YMCA' we tore up the dance floor and made many new friends!

 Extremely blessed and thankful...S&S