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....

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.”

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,
example:

- 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.

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!

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!!