back at home

Here is a quick recap of my last week.
Monday I worked at Port Maria for my last day. I saw 27 patients. I delivered the last batch of donated medical supplies that I brought (I had collected supplies for 4 months and filled my 2 checked luggage bags with them).
Tuesday I went shopping in the local market and then packed everything up. It didn't feel like a whole month had passed already. One of the nurse's house had caught on fire over the weekend. I left some of my clothes and travel sized toiletries for her. I ran into the general manager at Couples and told him about her. He took her name and number to send her some stuff too. I also had to say my goodbyes :( I had made some good friends at the resort (some employees and some guests).
Wednesday was travel day. My flight took off at 7:55am but since it is an international flight and the airport is in a different city my taxi left the resort at 3:15, yes that is 3:15AM. When I got to the airport it was completely empty! Nobody inside, not even an employee yet. It opened about 15 minutes later. I flew from Montego Bay to Miami then home to Memphis. I was greeted by my hubby who then took me out to lunch but then had to go back to work. I didn't mind though because I needed a nap.
Thursday I got to make my return to my residency as a speaker at our noon conference (not about Jamaica but that one will come). This weekend our hospital is making a huge move into a brand new building.

Overall my impressions: This rotation is great because it teaches you to feel confident in your physical exam (xrays and labs are not readily available), it gives you an opportunity to spread up to date information, it helps you appreciate what you have. The accommodations are awesome. The resort is so fun and the people there are happy and full of energy.
With all of the great things you should also know that not everyone would enjoy this rotation. You have to be comfortable treating without someone constantly over you. There is someone available if you run into a situation you are not comfortable with but most of the time you are on your own. You are the one making decisions. Also you have to be somewhat laid back. I'm a planner and organizer (of my time not my stuff) therefore I had a few frustrating moments mostly revolving around transportation.
If anyone has any questions about my experience feel free to email me at arouster@uthsc.edu

Happy Thanksgiving

Happy Thanksgiving everyone! There's a ton of things that I am thankful for, one of which is this experience. Since medical school I have wanted to participate in a medical mission trip. I came close last year. I had a trip to Guatemala planned but then fellowship interviews got in the way. The main roadblock has been the cost. I am grateful for the Issa Trust and Couple's Resort for organizing such a wonderful program.
Yesterday I rounded on the Pediatric ward with the team. I had it wrong before when I thought the 3 young docs there were residents. They do not have residency programs. Medical school is longer (6 yrs instead of our 4yrs) but they are not required to do a 3 yr residency.
Rounds are similar to ours. A younger (and I use this word as experience not necessarily age) doctor presents their patients to the Attending doctor (aka the Boss). A plan is pretty much set ahead of time but fine tuned after some discussion.
After rounds blood is drawn for the labs ordered. Then LUNCH.
I rode home with Candi again. The hospital system is down a car (its in the shop) so any time she offers I accept. On the ride home we stopped at this jerk shop. I had heard from all of the drivers that it has the best jerk (chicken and pork). It was good but Doug cooks pork so well that I'm pretty spoiled (dry pork just doesn't cut it anymore).
Today I watched the Macys parade and I'm going to watch Charlie Brown's Thanksgiving at 8pm. I got to talk to my family after they had dinner. Hopefully next year I can sit down with them at the table (last year Doug's grandma died so we were at his family's, 2 yrs ago I was on call, 3 yrs ago I think we were also at Doug's, so it must have been 4 yrs ago at my family).

FUN Jamaican stuff:
some schools have 2 shifts: 7-12 and 12-5. So if it seems like there are always kids walking around town, you're right.
The biggest shopping day of the year here is Christmas Eve.
Some of the rural houses just have the living area and bedrooms inside. The bathroom and kitchen are outside.
Speaking of bathrooms there is something called a pit latrine. During rounds we talked about this and I thought they said piG latrine and asked if I knew what it was. I thought pig trough and said 'where they eat.' Oh no. It is an 8 ft hole in the ground with a seat at the top of it to do your business.
Coconuts are not brown while they are on the tree. They have an outer shell that is yellow/green. The sweeter the jelly (juice) inside means the older it is. Milk is NOT the liquid inside but made by grinding up the white meat.

Pandora, Hulu, and Netflix do not work outside of the US.

wow time is flying

Last Wedneday I was rained out of clinic (flash flooding of some of the roads). Here things bounce back quickly though. In September they had bad flooding during tropical storm Nichole. I was told that there was 3 ft of water in all of the buildings in downtown Port Maria. The whole city was back up and running in 2 days. The water receeds quickly and since everything is concrete they just swept out the mud and went about business as usual.
Thursday I worked in the Annotto Bay clinic. You see a mixture of newborn exams, hospital follow ups and sick kids. Mostly well though. I rode back with Candi (one of the other docs at Annotto Bay) and she said we should go to the market sometime. What better time than right then? We poked around at the market. I bought one thing at the very end (shirt for my dad). I appreciated her going with me. When we got back to the resort SURPRISE my husband had flown in for our anniversary (5 yrs Nov 19th).
Friday he went with me to Port Antonio. It was great because that is my longest drive and he got to see all of the countryside. I also do outpatient and inpatient work there so he got to see it all.
We had a wonderful weekend. The resort has a flag system (green= all water sports are on, yellow= some of them, red= no sports). It was really windy so Sat and Sun were both red flag days. We still had an awesome anniversary!
Doug left Monday at 3am (I take the same early flight next Wed morning).
Yesterday and today were outpatient clinic days at Port Maria. I set a personal record for the # of patients seen in a day (27)!
Tomorrow is inpatient Annotto Bay. Thursday I will celebrate Thanksgiving. Friday back to Port Antonio. One last weekend of fun. Last work day is Monday!
I can't believe how fast this month has gone.
Now time for fun Jamaican stuff:
When you ask a kid what grade they are in the will say one, two, etc. Not first, second.
Many people here believe strongly in home remedies (pepper in your mouth for a sore throat, the leaf of a certain tree placed on the head for a fever, different roots and plants etc).
Once you finish grade 11 there is an option to do grades 12 and 13 but you have to be accepted. I don't think many people do it.
People complain about the government here too.
Ummmm I'm running out of things.

Monday the 15th

Today was another clinic day in Port Maria (roughly 30 minute drive). It seemed slower but that was because there was a heart screening going on at the same time. This made the patients flow more steady instead of a huge rush.
I saw 19 patients today.
Found out that they don't carry Claritin/Loratadine in the pharmacy (I've probably written 10 scripts for it and today was the first time someone came back in to tell me the pharmacy didn't carry it).
The very last patient I saw was a bit frustrating. She had viral pharyngitis. I spent awhile explaining the difference between a virus and bacteria and how we do not treat viruses with antibiotics. Mom and 12 year old seemed ok with this but then they came out and told the lady that had asked me to see them about my diagnosis/treatment plan. I had to leave my room to walk to the pharmacy. When I came back they had taken the chart (which they call a docket) and put her in line to see the nurse practitioner!
This is a common battle we fight in the US as well. Viruses are not treated with antibiotics but families sometimes get upset when you explain this. Studies have supposedly shown that if the doctor explains the nature of the illness that they family is ok with not getting a prescription. I have not found this to be very true (here or at home). Also, we are not supposed to give cough and cold medicine to anyone under the age of 6 years. I had a mother last week tell me that she wanted a prescription for their local cold medicine for her 9 month old baby. I explained why we don't give the medicine (risk is greater than benefit). She demanded 2 more times for me to write it and I finally had to say "you can leave now because I will not write you a prescription."
Please don't get me wrong. The vast majority of my patient encounters are pleasant and the families accept what I tell them. I just needed to vent about those.
Today I admitted a child to the Annotto Bay hospital. I hope he is still there on Wednesday when I do hospital rounds there. He is not growing and developing and has frequent infections (this is not a good combination).
Tip of the day: Don't travel with black luggage.
Time for Jamaican fun:
They report time like this: 1 day= 1/7, 1 week = 1/52, 1 month = 1/12
$1 US = $84 Jamaican
Their version of Sprite is called Ting
Kids here do not think of Santa Claus like we do. He is a figure at Christmas but he doesn't come down the chimney (they don't have them) and bring all of the presents. He rides on a donkey that pulls a cart with some toys in it. On Christmas Eve kids dress up in their finest clothing and walk around the town with their parents. They buy toys and candy that night as their gifts.

time for fun

Friday was my first trip to Port Antonio. As with any first day it started a bit rocky. I called the day before and confirmed a driver, apparently the staff knew I was coming but nobody told the driver :( I finally made it to the clinic around 1:30 and there was a whole waiting room of babies. There were 5 scheduled but word spread and a few extras showed up (I think there were only about 10 total but the waiting area seemed packed). After I saw clinic patients they took me to the inpatient area where I saw the 3 admitted babies, all 3 wks or younger. I actually had a wonderful day it just started late. My driver was really nice and he navigated the windy, pothole stricken road with grace. The nurse that helped during the clinic was fantastic. She actually stayed in the room with me to learn and to help with any language issues (we didn't have any).
Packing tip: Harriet Lane!!! I am using it frequently (for those that don't know it is just a reference text that fits in your pocket, well your very large pocket).
I had been told that flexibility is needed to do well at mission work. I understand what they mean now. We frequently stop at the gas station. We make stops at hospitals along the way to trade supplies. I have traveled with patients that are being transported to other hospitals (when you transfer to a higher level of care they do not go by ambulance but they just sit in the back of the car with a nurse). I don't mind any of it because this stuff has to happen anyway so conserve in your trips from here to there.
Fun Jamaican stuff: Almost half the cars here are Toyota. Originally I thought they must be the best then but I learned that the parts are the cheapest and easiest to get. By the way if you own a Toyota I can tell you that one of the first things to go out is the speedometer followed by the passenger windshield wiper. The horn though seems everlasting.
Many Jamaicans opt not to get officially married and just do the common law thing. Even if they do get married rings are not always involved.
You will commonly see an infant with a red hair tie on their wrist. Apparently they are supposed to have something red on so that they are watched over.
They dislike the cable companies as much as we do!
I mentioned before most of the buildings are concrete. They have metal roofs. Mostly concrete flooring. No air conditioning (mainly only for businesses) and of course no heater (no need). Instead of billboards and free standing signs they mostly paint on the concrete wall to advertise.
People do with what they have. Unlike Americans if a sister passes down a pink backpack or a purple bike the Jamaican boys will use it. Keep this in mind when examining babies because sometimes boys will have on pink and purple striped socks.
You can't get a license until you're 18. You can also drink at 18.

Ok so the title of the post was time for fun. It is Saturday so I didn't work today. I went to Dunn's River falls, which was fun. Played 3 games of beach volleyball. Read a book by the pool and now its dinner time! Sorry I can't post pictures but I forgot the adapter for my camera to load images onto the computer. I am taking plenty though so when I get it I will add them.

almost done with week 2

I've been slacking on my posts!
So I worked Monday and Tuesday in the clinic in Port Maria. Monday 15 patients. Tuesday 22 patients. Most common diagnoses: fungal infections and colds. I did send someone for labs and asked them to come back next week so we will see how this process goes (will the results make it into the chart? will the mom come back?). She was about 18 months old and had fallen pretty drastically off of the growth chart.
Wednesday I went to Annotto Bay and rounded on the inpatients. Attended another Csection delivery. This one was only 32 weeks gestation so I was nervous but he did great. Oh I needed to give Thao an update- I saw one of the triplets, baby #3. He was admitted but for just a bad cold. He is doing good! Today I went back to Annotto and worked in an outpatient clinic. Mostly hospital follow ups. I had a long conversation with one of the other Peds doctors. He takes call overnight at the hospital 3-4 nights a week. It is just him and another doctor to split up the days. This is because of the shortage of doctors (one took a few months maternity leave and I forget why another had to take some time off).
Fun Jamaican stuff- they use a lot of concrete when they build here (houses, fences, etc).
The vast majority of women breastfeed here, which is wonderful. It is normal to breastfeed in public and for children to still be breastfeeding at older ages than in the US.
There is a college in Kingston which services a large area. You go there for almost any degree you want but they will charge you differently based on your intended degree.
Animals I see daily- lots of stray dogs, goats, and chickens.
Kids don't have to be in carseats but you will get a ticket if someone under 12 years old is in the front seat.
They do not observe daylight savings time so I was on Central time when I first got here and now I'm on Eastern time.

Ok so tomorrow I head to Port Antonio. It is in a different parish (like a state here) so a new driver will pick me up. Called today to confirm this so tomorrow should be smooth (fingers crossed). I didn't go last week because of the storm and it is pretty far away.

starting week 2

So work was cut short last week due to tropical storm Tomas. Roads flood easily here and with the heavy rains I was stuck at the resort (sounds awful doesn't it).
I had a wonderful weekend: played pool volleyball, cricket, almost finished my book.
Today my day started out wonderfully because I learned they have peanut butter here!! I made a peanut butter and jelly sandwich to pack for lunch.
Arrived at the clinic, which was packed with kids waiting to be seen. I saw 15 kids again today. Diagnoses included: scabies, tinea, tinea, tinea, scabies, strep, virus, virus, virus.
I asked the ladies in the clinic what they needed and their response: a scale for infants and a bassinet to put infants in if the mom has to leave the room (I think they are called Moses baskets at Babies R Us).
Interesting Jamaica facts: all kids start school at the age of 3yrs.
They write the date starting with the day then month then year. This messed up all of my medical records the first day because I couldn't get the birthdates right.
Packing tips: you may be here by yourself so spray on sunscreen is a must and check your clothes before you leave- no sense in a dress that you can't button up by yourself.

Babies

Today I went to the hospital in Annotto Bay. When I arrived I was greeted very kindly and escorted to the Pediatric Ward of the hospital. The 3 residents were there working. They seem particular about about which year they are (first year=intern, second year=resident, third year=house officer). As an intern I used to get mad when people made the distinction between me and a resident. Residents are residents but that has no point here.
Due to the impending storm (aka Tomas) most patients had been discharged. There were only 6 there today. 3 of them were <1 week old (one there because mom's water had been broke for too long, one with a loud heart murmur, and one whose breathing was too fast). 2 were there primarily for social reasons (something that we commonly have happen in the US as well). 1 with pneumonia.
Once rounds started Dr. Ramos did some teaching and we quickly noted some major differences in our practices. In the US we test every baby's bilirubin before discharge. We also have a device that will test it without drawing blood (transcutaneous bilimeter). Here they have to stick an artery for blood! This may not sound like a big deal but when we draw blood at home we do what is called a heel stick. Basically we prick the heel and milk out blood. They don't have equipment to measure capillary blood sample (which is what the heel stick is). They draw all their own blood samples and walk them to the lab!
During rounds we were called to the operating room (which they call the OT or operating theater) for a Csection delivery. I invited myself along. WOW this was different. In the US when a pediatric resident goes to a delivery they are accompanied by a respiratory therapist and a nurse (if it is an intern an upper level resident also goes). Just the intern went (and me)! She had to test all the equipment herself and actually wait at the foot of the bed to take the baby (they bring the baby to us). In the US we are obsessed with keeping the baby warm (put on the hat, use about 5 blankets because as soon as one is wet you throw it off the table, and the baby is not allowed off the warmer for more than a few seconds to get weighed). Now this being said we are in an air conditioned delivery room where there are people who like to turn the temp way down. Here we had 2 blankets and no hat. The first was used the entire time we resuscitated the baby and the second only when we took the baby out of the room (by the way no triple checking identification bracelets and getting footprints- we just took the baby out the door after saying loudly to the room- Baby girl X delivered at 11:48 am). We took the baby to the maternity ward where we took all of the measurements, wrote a note and left the baby with the nurse.
When we got back to the Pediatric ward rounds were over so we headed back to the maternity ward to discharge babies. Here they give the BCG shot (for tuberculosis) which we do not give in the US. They do not however give the hepatitis B vaccine that we give before discharge. Baby boys are not circumcised before leaving the hospital either (most are never done).
This was a long blog today so I am just going to stop babbling.
Take home point: a transcutaneous bilimeter would be awesome here!
Fun Jamaican fact of the day: if you were a car horn you would be very busy
One last random thing I have to tell you about because it blows my mind. They do not have school buses here. When school lets out the kids walk down the side of the road and random people pick them up and drive them down the street! This happens with everyone, not just school kids. People just pull over and pick you up if you are walking. People are just nice to each other. Nobody worries about kidnapping, rape, and all that. Crazy- but in an awesome way.

First day of work

After a small delay I was off and running this am at the clinic in Port Maria. My exam room was small but sufficient.
Equipment I used today: stethoscope, otoscope and tips, ear curettes, measuring tape, and a pen light. I also used hand sanitizer and sanitizing wipes (out of my awesome fanny pack).
Diagnoses made: well child, fungal infections, seasonal allergies, headache due to poor vision (refer for glasses), tonsillitis (recurrent- refer to ENT), strep, viral gastroenteritis, and foreign body in the eye (sand).
Survival tip: take food. I took a plantain and apple from the breakfast buffet.
Interesting point of the day: my father in law has a saying "drive fast and take chances." I think the drivers in Jamaica live by that phrase as well.

Day 1

My trip went smoothly. I checked bags for the first time ever and they made it without any problems. One bag did get searched and I don't know how the lady got it all back in without sitting on it but she did. My flight went from Memphis to Miami then to Montego Bay. I had a 3 hour layover, which was extended a bit. Luckily I was not one of the unhappy travelers whose flight had been cancelled earlier in the day (hence my short delay because they had to find us a bigger plane to put all of the morning people on too).
When we touched down in Jamaica everyone had to go through customs. This process went smoothly as well. After claiming your luggage you head to the resort's lounge. It is decorated in bright colors. They offer water or Red Stripe while you wait for the rest of the guests. Then you all board a bus and head to the resort. It was about an hour and a half ride. The driver made it fun though by telling us all about Jamaican foods, words, customs, etc.
I arrived at my room around midnight. It has a courtyard in the front with lounge chairs and a table. You walk in to a large living room. There is also a kitchen area, dining area, and office space. As well as 2 bedrooms each with their own bath. One bedroom door was open but the other had a Do Not Disturb sign on it so I didn't go in there until this am. I bet the sign was there so the cleaning ladies didn't bother with that room if only one person was here last month too.
I got up today, had breakfast (the french toast is awesome) and then did the resort orientation with Brenton. He is one of the Entertainment Specialists. This was a helpful 30-45 minutes that I recommend. I rented a book from the library (Wicked) and did some sun bathing. I wish I could bottle up the ocean breeze! Rafael led an awesome aerobics class and then I somehow got sucked into the spinning class that followed. Paula led that. She was fun and helped all of us first timers.
Tonight there is a meet the managers beach party and then a steel drum band playing. I might take my laptop and Skype Doug (my husband) into that! He loves that type of music.
Tomorrow is my first day of work. I have my fanny pack all packed and ready (yes I really do and yes I know I'm a dork). I'll have breakfast at 7:30 and then get picked up at 8am to start my adventure.

Sad to say goodbye

It did not really hit me that I finished my one month of pediatric rotation in Jamaica until now when I'm packing my suitcases to head back to the States. What an INCREDIBLE month it has been! I think one month is an adequate amount of time to learn about the culture of medicine here in Jamaica and then becoming comfortable with it to apply to the daily clinic and hospital work.

The one most important thing that I learned after working here for a month is FLEXIBILITY. One needs to be flexible and ready to adapt to work in a less than optimal clinical settings, but still be able to provide the best of care.

There are several things in Jamaica that will always be dear in my heart. Jamaicans are some of the nicest people you'll ever meet in your life. People always greeting you with a smile and passing around the vibe of "no problem" on this island. The food is inargueably delicious, especially the jerk pork at Scotchies (and I'm not even a pork fan). The children here are so adorable in their crisp and colorful uniforms, holding hands and walking to school together (there is something so endearing about this), always politely addressing you as "yes, miss", "no, miss". The lush green vegetations of the mountains and the aqua blue of the Caribbean Sea provide the best scenery that I never get bored off looking out of the window on my daily ride to the hospitals.

I HIGHLY encourage third-year pediatric residents to embark on this awesome journey. I am thankful to the ISSA Trust Foundation and Couples Resort for its sponsorship, to Diane and Stacey who gave me this golden international opportunity, and to Oakland Kaiser Permanente (my residency program) for supporting me with this brand new rotation. I would definitely do this rotation again in a heart beat.

Below is another cutie patient of mine that I won't forget (permission obtained from mother).




Jamaica, you will be missed!

Week 3...cruise control

I remembered my first day of work here in Jamaica, there was a lot of things that I was not familiar with. Now, more than half way thru this month, I have established a routine and I am comfortable with it. I am more confident now about my clinical diagnoses, which is the predominant tool that one has here, when there is a lack of resources such as Xray, exotic labs and cultures, CT, MRI.

The diagnosis themes for this week are dengue fever, asthma exacerbation, and fungal infection. Dengue fever is real! The outbreak currently reported to have one associated death and 4 confirmed cases of hemorrhagic dengue fever. This week in clinic on one morning, I saw 5 children back to back who ALL came in with complaints of fever, headache, eye pain, and leg pain. These are classic symptoms for dengue fever. The children looked well and there was low concern for hemorrhagic or shock. I sent them to the lab for dengue fever screening which includes dengue, malaria, hepatitis, leptospirosis. I discussed with the parents that there is no specific treatment for dengue, just mostly supportive care with Paracetamol (that is what Tylenol is called here) for fever and/or pain, avoid use of Ibuprofen and aspirin as there is increase risk of bleeding, and to return if there is any signs of bleeding or changes in mental status.

This time of the year with rain and quick changes in weather, asthma exacerbation is quite common here in Jamaica. I actually admitted 2 children this week from clinic to the pediatric ward for management since they failed to improve after Salbutamol nebulizer treatment in the ED. Salbutamol (international nonproprietary name) is just another name for Albuterol (United State adopted name). The children on the ward get nebulizer treatment every 4 hours. Often they are not hooked up to any monitor such as pulse oximetry. They walk around on the ward and play with other children. I was thinking to myself when I rounded on my patients on the ward the next morning about how do we know if they desat when they sleep at night? I guess we just have to rely on lungs exam and how they look clinically. I am happy to report that my 2 children did well, likely to go home after being transitioned to Salbutamol MDI and prescription for Beclomethasone MDI.

This week I saw a girl who was referred to me by the medical mission team from CHOP with random glucose of 430. She has known type 1 DM (diagnosed when she was 6). When I saw her I cannot believe how well she looked for someone with a sugar of 430. She was very pleasant, conversing with me about her diabetes camp experience (they have diabetes camp here!!!!), her insulin regimen at home, and her glucose normally runs between 100-150, so 430 is definitely not normal for her at all. Luckily, she was not ketotic or acidotic based on her labs. We gave her subcutaneous insulin and her glucose decreased to 288, which was still relatively high, despite her well appearance. She was not very happy when I told her that she had to stay in the hospital overnight. However, when I saw her the next day, she was smiling at me and getting ready to go home.



The drive to Castleton clinic



I spent one day this week at Castleton clinic. It is another one of those small clinics in the rural moutainous region of Jamaica. The drive there is rough but extremely beautiful! The lush green vegetations are mesmerizing, resembling a tropical forest. Coconut and banana trees are abundant. I was not surprised to arrive at the clinic and found that it was already packed with patients sitting in a cramped small room waiting patiently to be seen. I WAS surprised when the nurses informed me that there is no water anywhere in the clinic. Thank god for my hand sanitizer! My first patient came in with complaint of ear pain. I asked the nurse for a plastic ear tip but she told me that there was none. I frantically searched my bag and luckily I came up with 2 ear tips. It would have been a challenge to check the ear without an ear tip when someone is complaining of ear pain. For future docs, it is not a bad idea to stock up on ear tips, ear curettes, and hand sanitizers.

She is such a cutie! Look at that smile! (permission obtained from mother for picture)

My time here is Jamaica is winding down and so far it has been an AMAZING experience! I have learned so much and met so many wonderful people. This is such a beautiful country.

Week 2....work hard, play harder

This past week started out rough with a big storm (at least in my opinion) but the native Jamaicans here called it "heavy rain"....not enough wind to call it a storm....but it was pretty scary nonetheless...heavy pouring rain, lighting, and thunders that literally made you jump out of your seat....I have not seen weather like this in a while. Driving to the clinic was of course more challenging with flooding roads and potholes. The drive to the remote River Rock health clinic (located high up in the moutainous areas of inland Jamaica) was so nauseating from dodging potholes, and the width of the road barely enough for two cars to pass. My patient load was somewhat affected on these rainy days, but of course it picked up as soon as the sun came out again. Sometimes midweek I was relieved to learn that Hurricane Igor has diverted away from the Caribbean.

The clinical experience themes for this week are newborn exams and school physicals. Actually, it was somewhat refreshing to see well children after so many acute care visits. I learned that here all children receive BCG at birth or shortly after birth. Varicella vaccine is not readily available so unfortunately it is still not part of the standard vaccination schedule yet.

I have diagnosed quite a few tinea capitis (a very common fungal infection here in Jamaica). What I found interesting was typically in the States, we would initiate oral Griseofulvin for treatment, but here in Jamaica, often the clinicians will prescribe antifungal shampoo and cream as a first line of treatment before considering Griseofulvin. Often cost and unavailability in the pharmacy are the factors. Also monitoring of hepatic function can be difficult as patients often are lost to follow up.

Despite my vigilance about mosquitoes and constant use of repellant, I still managed to get bitten by these crazy bugs....man and talk about pruritic rash....drives me crazy! There is currently a dengue fever outbreak in Jamaica. I actually saw a patient in the clinic this week that I suspected that he has dengue (fever, headache, eye pain, arthalgia, weakness). Dengue fever is caused by Aedes mosquitoes. It is sometimes also known as "breakbone fever" because of the joint pain. Complications include dengue hemorrhagic fever or dengue shock syndrome. Treatment is supportive care. Luckily, most cases of dengue are either asymptomatic or mild. So far I'm good....crossing my fingers.

I finally met the medical mission team from Children's Hospital Iowa this past week! What an amazing group of people, so incredibly friendly, caring, and fun. The team went to several of the hospitals that I work at, however, on different days, so I never actually worked with the team. Every night, after a long day of hard work, we dine together, share stories, and dance the night away, but of course within a reasonable curfew, so we can all get ready for the next day of work. Today marked the end of the one-week trip. We were all treated to a wonderfully hosted and delicious dinner as a token for our hard work. I will definitely miss them! We will keep in touch most definitely!




As for me, the weekends have turned out quite well since it was the only time I have off. The excursion to Dunn's River Fall was incredible. My adventurous side took me sailing, kayaking, beach volleyball, hydraulic biking, and a feeble attempt at water skiing (it turned out my feet were too small to fit into the skiing shoes and I was consider high risk since I cannot swim...still working on that). I also got a chance to eat authenic jerk chicken and pork at one of the best jerk restaurants in Jamaica (Scotchies!).




I cannot believe that I only have about 10 days left here in Jamaica. Where did the time go? This upcoming week I will meet the medical mission team from Children's Hospital Philadelphia.

Until next time....

Week 1...learning the ropes

My first week in Jamaica has been extremely BUSY! I worked at three hospitals with adjacent outpatient clinics on different days of the week, saw a ton of patients, befriended many Jamaican medical staffs, picked up quite a few native Jamaican terms, learned to tolerate the humidity, AND already am the victim to mosquito bites despite my repellant. I am very much aware that there is currently a dengue fever outbreak warning in Jamaica.

The diagnosis themes for this week are skin infection, skin infection, AND skin infection. I honestly have never seen so many cases of impetigo and furuncles/carbuncles in my entire life. I've written god knows how many prescriptions for Keflex. Skin infection is VERY common here in Jamaica considering its tropical weather that is quite inviting for the mosquitoes. The children play outside a lot and wear short pants and skirts making them more susceptible to mosquitoes. Mosquito bites are incredibly ITCHY (I know!), scratching breaks the skin barrier, and leads to superimposed bacterial infection. Many children have scarring on their arms and legs from recurrent skin infections such as the picture here (I have obtained permission from the patient and her mother for taking the picture).



The clinics are very busy. There is always a long line of patients to been seen way before the clinic even opens. Often, I don't even have time for lunch because as soon as I'm done with one patient, the next one comes in, and I just feel bad that they have been waiting for a long time so I just kept on going. At Port Maria clinic, I'm essentially the ONLY pediatrician there, so I get all the referrals from the main health complex and from the ER. One day I saw as much as 23 patients! Insane right? On the contrary, at Annotto Bay clinic, the workload is somewhat lighter since there are one regular pediatrician (Dr. Ramos) and one Jamaican resident working alongside with me.













My office and exam room in Port Maria


The biggest adjustment for me was going back to paper medical record style. Deciphering handwritings from previous physicians who documented in the docket (medical chart) can be so tricky. Often the dockets are incomplete or out of order and can take sometime to figure out what has been going on with the child. Writing in the chart and prescriptions also takes time. Sometimes I feel so pressed when I know there is probably a long line of patient waiting outside my exam room. To my fellow residents back home in Oakland, California...we are so blessed with our electronic medical record!

Another challenge for me this week was understanding the native accent. Jamaicans speak English as well as their native dialect called Patois. Sometimes the accent is heavy and I can barely understand, but I'm learning. After I talked to some of the medical staffs, here are somethings that I've picked up... "water bump" means pustule that ruptured, "tonic" means appetite stimulant (mothers keep asking me to prescribe vitamins as "tonic" for their children), "du du" means poop.....

The drive to the hospitals is variably long (anywhere from 30-minute to 2-hour drive). The views of the majestic aqua Caribbean sea and the lush green coconut and banana trees on the periphery somehow miraculously suppress my car sickness and made the drive quite pleasant.
I have yet to use my Meclizine.











Coconut and banana trees, Caribbean sea (along the drive to Port Antonio)


My plans for this weekend: hopefully testing out the Caribbean water with some fun water sports and finally meeting the medical team from Children's Hospital Iowa.

Until next week.....

Arrival to Jamaica

After half a day of traveling from San Jose, California, 2 stops, and being delayed at Miami Airport, I finally arrived to Jamaica very very late last night. On top of that, my check-in baggage was missing, so I spent my first night in Jamaica unbathed and without any clothing change. However, when I arrived at the resort, everyone here was so incredibly accomodating and understanding. The manager of the resort even offered me a free shopping spree at the gift shop so I can have change of clothes. I moved into the private villa today, and it is FABULOUS! I was informed by the front desk that my baggage should be delivered to the resort this evening....thank goodness! I was very worried since I have my clothes, toiletry, books, medications, and medical equipments in that bag. Anyhow, rough start but I'm so thankful to be here. Jamaica is so beautiful! I'm very excited to start work tomorrow. Let the month begin!

Jamaica Pediatric Mission: August 4th , 2010 Port Maria Clinic

Jamaica Pediatric Mission: August 4th , 2010 Port Maria Clinic: "Late yesterday, I found out here was a room a nearby, (technically in the hospital building )the pediatricians use for HIV clinic. I didn't ..."

Jamaica Pediatric Mission: August 3 2010, Port Maria

Jamaica Pediatric Mission: August 3 2010, Port Maria: "The drive to Port Maria was scenic, with the route mostly along the northern coastline, showing glimpses of the beautiful Caribbean Sea. Th..."

Jamaica Pediatric Mission: Well, I finally arrived at Couples Resort last nig...

Jamaica Pediatric Mission: Well, I finally arrived at Couples Resort last nig...: "Well, I finally arrived at Couples Resort last night. I spent the past 2 days in Kingston and left on Sunday afternoon, for what I hoped wou..."

Day 08 - Usher and Shaggy are in Jamaica!

A hearty breakfast every morning. A great cup of coffee. Amazing view. Yeah, I can get used to this.

I was eager to get to Port Maria today so I could check in on the one-year-old boy we saw last week who had been scalded by boiling water. Stacy and I were worried about his pain management and the adequacy of monitoring such a young child's fluid balance. I'm happy to report that he is doing much better. In fact, I couldn't find him in his bed because he was out and playing around. He was scheduled to be discharged today. Dr. Fazul had followed our recommendations for pain management using morphine and he reports that the baby was very comfortable during the last week. He has been eating well, and his skin looks very healthy. His mother came and gave me a hug saying, "thank you for loving my child". That's it. That's all the compensation I need.

Dr. Fazul and I rounded on another 8 patients. The pediatric ward here has the luxury of being split into three zones, so the four children admitted with gastroenteritis were physically separated from three newborns and another one-year-old girl who had been admitted two days ago with a burn eerily similar to the first boy's burn. I learned an interesting tidbit of information when I asked if the babies were receiving expressed breastmilk and if the hospital provided mothers with breast pumps. Apparently, the mothers actually express their breast milk manually, using their hands (this is how). I didn't know this was possible, and I'm happy to hear that it is, but a part of me wonders how many more mothers would provide expressed breast milk if they had the manual breast pumps that many US hospital provide free of charge to new mothers.

I saw five patients in the clinic after rounds: two were follow-ups for asthma, one was a well child visit for a month old newborn (yes, they do well child visits here), one was case of pretty bad tinea capitis that had failed management with shampoo that a private doctor had prescribed, and one was a child with occasional dizziness spells that I sent off for some tests and asked to follow-up next week.

I had a little time to speak with the folks at the registration and scheduling office. They are now offering parents who call for a pediatric appointment the choice of a Tuesday clinic (when Dr. Ramos is here) and a Friday clinic (when one of us will be here, hopefully regularly). They've integrated us, and I love it!

Before heading back to the resort one last time, Steve and I went to Scotchy's, which has the reputation of being the absolute best place to have jerk bbq in Jamaica. I came here last week with Diane, Stacy, and Alex and I couldn't bear to go home without pigging out again.

Today is my last day here and I'll be happy to get back to my family. But I've had a tremendous experience here. Having a regular schedule, and actually filling in a gap in each clinic is very gratifying. Working with the hospitals rather than in parallel to them is beneficial to the long-term well-being of child care in Jamaica. I've gotten to know the pharmacists, the lab technicians, the attendants, and the other physicians and I feel that we are now a unified force. Great things are coming. We are learning new lessons every day, and the "orientation manual" that Stacy and Diane are writing is being updated on an almost daily basis. There will be kinks, but that's the best way to learn and to improve. And being able to come home to the luxuries of a beautiful resort and rest in a great bed is nice icing on the cake.

This blog will be open to posts from the future physicians and nurses who take part in this mission. I'm looking forward to reading about others' experience here. Thank you all for following my journey with me. The emails you sent me and the comments you posted were very inspiring.

Day 07 - Visiting the triplets again

The outpatient department in Annotto Bay - the patients wait outside

I received some bit of good news today when I passed by the pediatric ward in Annotto Bay today. Baby B of the triplets has been able to come off of CPAP and he has been making good breathing efforts. This is the baby who had omphalitis so having one less thing to worry about makes his care a bit easier. I was able to uncover him completely to do a full exam. His omphalitis appears to be under good control. His breathing is unlabored. His right foot is a little poorly perfused and the little toe is looking a little dark. I asked the nurses to place some warm packs on the left leg to improve perfusion. The nurse tried to correct me and asked if I meant the right leg. A great opportunity for a teaching moment!

They are going to try Baby A off of CPAP today. They tried last night but he wasn't quite ready. Dr. Ramos has to make an educated guess as to when a baby is ready to be taken off of CPAP. The babies have never had an X-Ray, because the machine has been broken (since February). We cannot monitor blood gases - they don't have that capability at all.

Triplet C, our sickest one (with possible sepsis), was a little swollen. Dr. Fisher, the senior resident, said that he had low protein levels (hypoalbuminemia) and they had given him some intravenous albumin. This is only going to get exacerbated by the limited nutrition. But at this stage I'm also worried about the kidneys. We have no way of closely monitoring the urine output. On my way back from the clinic yesterday I stopped by two "supermarkets" but neither had a scale. Bobbi - the scales you are bringing will be a lifesaver! Literally. Thank you! Thank you! Thank you! (one from each of the triplets).

Our makeshift NICU has a new addition. A 29 weeker was born yesterday and he weighs about 3 pounds. He's doing well. He is being kept in the nonfunctioning incubator, but at least it is a barrier from infections. He is breathing on his own and he may get fed today.

In the next bed I saw a mother cradling a baby who looked limp. I found out that this is an 8-month old baby with a severely malformed heart - DORV with TGA and VSD/ASD (for my PICU folks). This is a condition that typically requires intensive monitoring and very VERY close observation. He would typically require the collective efforts of a cardiologist, cardiac surgeon, intensivist, and nurses adept at caring for children with congenital heart disease. Yet, he's had no X-Rays.No lactate levels. And he wasn't hooked up to a heart monitor. Dr. Ramos explained that all the available heart monitors are being used. It is a tough decision, but I can't help but agree with the premise. Limited resources must be distributed where they can have the greatest impact. This child's condition is very complicated. He will likely require several cardiac surgeries or even a heart transplant. I spoke with the mother and she barely had enough money to get the first few echocardiograms. She said there is a traveling cardiac surgery team that will be in Jamaica in November. She hopes they will "fix his heart". Dr. Ramos and I talked about how we can prepare him for surgery. We will try to get him to gain more weight. We will monitor his kidneys. We will monitor for heart failure. Dr. Ramos will try to get him transferred to the capital but he's not sure if they will accept him.

Tomorrow is my last day. I will be going to Port Antonio. I'm looking forward to meeting Dr. Fazul again and seeing how he has been doing with our little kid with a severe burn.

Day 06 - Checking in on the triplets

This is where I have breakfast every morning. Yes, it's a tough job but someone has to do it.

Baby A - Note the Zip-Lock bag.

The first thing I did when I arrived to Annotto Bay Hospital is check on the triplets that were born on the day we arrived last week. They are 6 days old today. Dr. Ravi, a pediatric resident, was taking care of them when I arrived and he gave me the update. They can all best be described as stable, but they are having many of the complications that can be expected when they are in an inadequately equipped NICU. Infections are the most worrisome complication at this stage; all the babies had an infection of some sort. Baby A had an eye infection (ophthalmia neonatorum) even though he had reportedly been given preventive antibiotics. Baby B had an infection of his umbilical stump (omphalitis). And Baby C had signs of infection in his intestines (necrotizing enterocolitis) and possibly even signs of a worse infection (sepsis). They were all on adequate antibiotics and have a high chance of cure, however the conditions that set them up for these infections were still there.

Babies B and C sharing a cot - Note the many towels

The temperature irregularities (which actually now may be a reflection of their infections) are being treated by wrapping the babies with nonsterile towels, cotton, and fabric. Last time we were here, we recommended the babies be kept undressed under the warmers, with some plastic wrap covering the cot (acting like a greenhouse). This advice was only temporarily headed, as today they are still wrapped with all sorts of coverings, no doubt havens for bacteria. The use of a Zip-Lock bag in Baby A is ingenious, but clearly it is difficult for the caretakers to stop using additional fabric. Two babies are sharing a cot making it easier for infection to spread. None of the babies are in an incubator. Remember, these babies are sharing a room with other children as old as 13 years old, all of whom have bacterias and/or viruses that are making them sick enough to need hospitalization.

After infection control, nutrition is another top priority in caring for premature infants. However, intravenous total parenteral nutrition is not available. The babies are still receiving simple dextrose water. They will continue receiving this water until they are strong enough to receive formula into their stomach. However, Baby C (who might have NEC) cannot be fed because it could worsen the infection. He will be on sugar water for another week or so. Malnutrition sets him up to be even more easily infected and the cycle continues.

The odds are definitely stacked up against our kiddos, but the doctors are doing the best with what they have. They are using pretty much the same antibiotics we would use in the United States, and everyone is instructed to wash their hands before touching the babies. The bubble CPAP is still working fine. Dr. Ravi told me that he has stayed several late nights at the babies' bedside.

Last week when these babies were born, I remember telling Stacy and Diane that these babies had a good chance of survival. Infants born at 28-30 weeks routinely survive with minimal or no complications. I neglected to take into account that the many facilities we take for granted in our modern NICUs are absolutely necessary for that survival. I'm learning new lessons about what we can do to help. Sure they need equipment like the warmers we donated a few weeks ago. Those warmers allowed the babies to survive the first few days. But the next few weeks depend on education as much as anything else. Nurses would benefit from learning about warming techniques. And someone who has influence needs to see the value of a separate newborn care unit. In a country where the birth rate is 50% higher than that in the United States, there will obviously be enough babies to keep that room filled.

Walking outside of the pediatric ward, I saw the Adolescent and Child Mental Health Building. I suppose this was God's way of letting me know that all is not lost. The goat was the perfect accessory to help put a smile on my face.

Lesson learned
I wish we could get an adequately equipped NICU.

Day 05 - Nineteen children seen.

I arrived to the hospital at 8:45AM and I was the first one there. After making my way through the 30-50 families waiting to be seen, I reached the clinic door and it was closed. Not a big deal. I used the time to check out the emergency ward in the next building. It was an air conditioned small building with several rooms that catered to adults and children. The nurses still wear the quintessential nurse's uniform - white dress and white cap. I saw one teach a mother how to rehydrate her child. It is remarkable that dehydration from diarrheal diseases, considered simply a nuisance in most developed nations, leads to the death of nearly two million children in developing countries every year.

Soon the clinic doors opened and headed to Ms. Grant (I gave her an apple that I brought with me from this morning's buffet at the resort.) I was told I couldn't use yesterday's same room. It was the psychiatrist's room and today was her clinic day. I instead set up office in the nurse practitioner's room - she's the women's health person and she does not have clinics on Tuesdays. Playing office roulette is a routine that might change when the Issa Trust Foundation's resident program is in full swing and we have a regular schedule.

I saw 19 patients today. The nurses already knew that I would not see teenagers or do school physicals. A couple of parents knew this too and they registered their children for sick visits, but popped out the school physical form once they were in my office. These actions show the desperate need that these families have for pediatricians in the area. I feel privileged.

I saw a patient with what I thought was leishmaniasis, an infection that is common in tropical countries, and we heard from local doctors that they had been seeing cases here. This is a parasitic infection carried by a fly that thrives in unsanitary environments. After the child is bitten, a painless sore grows slowly and eventually ulcerates (cutaneous leishmaniasis). They can be superinfected, as was the case in my patient, and can spread to involve deeper tissues and possibly even causing death (visceral leishmaniasis). Bad cases of tinea can look similar, but tinea is intensely itchy whereas leishmaniasis is not.. Although the skin sores are ugly and fester for months, they tend to heal on their own albeit leaving behind ugly scars. The treatment is with paromomycin, which provides a cure in more than 90% of kids. The 21-day course costs $10. It is not available in Jamaica. Another treatment is with pentavalent antimony, which costs $60 and was not available either. I prescribed oral and topical ketoconazole and told them to come back in 4 weeks to see if the third-line choice was effective.

The ride home was a little more exciting than usual . I took a cab, and got a lecture from the cab driver about how corrupt the public transport system was. Apparently bus drivers and cab drivers aren't allowed to drive the same roads - each has a permit for a particular road. He called the bus drivers "big shots" who claim all the "good roads".

Lessons learned:
1. Everything runs on Jamaican time. Go with the flow and don't worry, be happy.
2. Learn the second and third-line treatment options for everything. First line therapy may not be available.
3. Make friends with a bus driver. They know all the "top people".
4. If you want to join in the karaoke fun in the resort, remember that they like to change the words - "Give me the beat, boys, and free my soul. I wanna get lost in the REGGAE world and drift away ... "

Day 04 - Port Maria Health Center

Would it be redundant to say it was a beautiful morning in Jamaica? 

This was the first day that I was on my own. Steve picked me up at around 8:15AM and we set off to Port Maria Hospital.  When I arrived, there were at least 50 people waiting to be seen in the clinics. I can see that Mondays in Jamaica are no different from Mondays back home.

I met Ms. Grant as soon as I walked into the clinic (she's the "female attendant"). She remembered the Issa Trust Foundation and was very helpful in getting me set up in an office. She asked me which age groups I was comfortable seeing and I said up to 18 years. I'd later find out that this was a big mistake. But what better way to learn?

I saw THIRTY-TWO patients today. Out of my first 15 patients, 11 were school physicals for teenagers. That's when I stepped out to speak with Ms. Grant to tell her that I would no longer see anyone above 13 (as is the norm for pediatricians in Jamaica), and that I would not see school physicals. I felt that they could adequately be seen by one of the three other MDs in the clinic. She rifled through my stack of charts and removed 15 or 20 charts. But before I could breathe a sigh of relief, 5 charts came, then 5 more, etc. I think the word was getting spread that a pediatrician was in the office! Alright!

Most of the sick children I saw were presenting with fungal infections of their skin, scalp, and mouth.When I was examining one 4 year old boy whose came because of ringworm on his forearm, I saw a ring around his iris. The mother had never noticed it. This is called corneal arcus, and can be a common finding in those older than 50 years. However, in a child it can be an indicator of hypercholesterolemia. When I asked his mother she told me that her brother had died at age 27 because of heart disease. I sent this child to have his cholesterol and triglyceride levels checked. He will follow-up in two weeks, on Monday or Tuesday, so he can see one of us!

A seven-year-old girl was brought by her father who wanted to check if she had had sexual intercourse. He said she hadn't told him anything, but that he heard "talk around the village". I asked him to step outside and I spoke with the girl alone. She was speaking patois, but I could make out a few key words: "he touch me", "he say me shut up", "he lick me". I wanted to make sure I wasn't missing anything pertinent so I asked for a nurse to translate. The girl said that this event had happened "a while ago". I examined her genitalia - the tear I saw was not fresh, but was most likely less than 2 weeks old. After discussion with the head nurse I found out what I had to do: fill out a referral form to the Child Development Agency (the closest one was in Highgate), place the referral in a sealed envelope, and have the father take the little girl to the agency today for a full investigation. If the father had been a suspect, then the head nurse said she would have arranged for someone else to take the girl to the Agency. Before she left, I gave the young girl prophylactic ceftriaxone and azithromycin, and treated a ringworm that I saw during her exam.

Lessons learned:
1. Only see sick patients. School physicals can easily be completed by a non-pediatrician.
2. Review dermal bacterial and fungal infections (I found this article to be very helpful). Study the severe presentations. I saw a child who had such a diffuse infection that he was losing weight! He's coming back for a repeat visit in 2 weeks too.
3. Child protective service and child abuse service are rolled up into one: the Child Development Agency.

Note: All patient pictures were taken with the written permission of the parent accompanying the child.

Weekend at the Couples Resort

The clinics are closed and it is time to rest. It is difficult not to enjoy yourself while you are here. The all-inclusive part of the resort includes almost all water sports. Scuba diving lessons and dive are everyday at 9AM. A bus departs everyday but Friday to the beautiful Dunn's River Falls, Jamaica's most famous waterfalls. You can go water skiing or knee boarding. Sailboating, kayaking, and pedal boating are all included. Couples' employees designated as Entertainment Managers arrange for daily activities such as sand and pool volleyball. And there are three different pools to lounge by, one of which has a swim-up bar.

I thought I would feel out of place being here by myself among guests that have all arrived as couples, but the group activities are geared to letting everyone get in on the action. When I sit by myself for meals, almost invariably one of the employees sits with me and we have a nice chat. It's been a few days and almost all of them know why I am here. They treat me with much respect and are eager to make my stay as comfortable as possible. One favorite greeting, "Respect", pretty much says it all.

Respect!

Day 03 - Port Antonio Hospital

Port Antonio is a two-hour ride away from the Couples Resort at Tower Isle. I still love watching the scenery during our ride. But anyone prone to carsickness should definitely premedicate with dramamine. The road is extremely curvy and the long ride is a good setup for some unpleasant feelings.

Port Antonio hospital is designated a type-C hospital - that is the lowest level of care. However, the buildings themselves actually look to be in better shape that both of the other clinics we've been to. Dr. Ramos, our partner Jamaican pediatrician, indicated that this location is in the most dire need of pediatric services.

Our contact here was Dr. Davis - she is a gynecologist. She introduced us to two other physicians, one of whom was Dr. Fazul. She called him a resident but he has been at the hospital for 6 or 7 years. I wanted to understand this more, but I figured that is a question I can ask later. Dr. Fazul was going to go to do inpatient rounds and we (Stacy and I) went along. There were 5 patients - two first-time wheezer infants (neither of whom had a pulse oximeter), a 5 year old girl with gastroenteritis (she was getting fluids - D5 0.45%NS - but without an IV pump), and a newborn who had been born at home and was being treated for presumed sepsis. There is no mechanism for local microbiology, so cultures have to be sent to Kingston (two hours away). Cultures are usually bundled to be sent on one particular day. Dr. Fazul expressed his frustration that even on the days the cultures were supposed to be sent out, often weather would impede or even cancel the transport. He therefor rarely obtains cultures, and treats empirically. In this case, the home-born infant who was otherwise doing well was going to be receiving cephalosporins for a week.

The fifth child was a 1 year old who had been admitted a few hours before we arrived. He had been reaching up to a pot of boiling tea and it toppled on him, scalding most of his right side. I estimated his burn at 15-20% of mostly third-degree burns. Needless to say he was in obvious discomfort. They were managing his pain with oral paracetamol, the equivalent of our tylenol. It was woefully inadequate. The child did not have an IV and was not receiving any IV fluids. He was at risk for significant fluid loss. The best way to monitor fluid status is by closely observing the urine output. They had no way of weighing his diapers as a method of monitoring his urine output. A $20 kitchen scale would solve this.

I asked them about morphine, but they were hesitant to use it. I gave them a dose to use and the nurse set about getting it. Since they have no respiratory monitors they were understandable worried about respiratory depression. However, as Stacy quickly pointed out to them, a child in that much discomfort would not likely  fall asleep from a minimal dose of morphine. There was a little "teaching moment" here - infants with burns are more likely to die from fluid loss than they are from infections. I ordered some fluids and let them know that he should have a full wet diaper every two hours.

Stacy and I went to our clinic after rounds. This was by far the most comfortable clinic we've had in the past three days. A fully air-conditioned room, with a nearby sink and refrigerator. This clinic sees patient on an appointment basis. I was scheduled to see three patients. We've been trying to get the word out that the pediatric clinic would be staffed on Fridays, and with time we will have more patients. Right now, most people are still used to only having the pediatrician, Dr. Ramos, available on Tuesdays.

My first patient was an 8 month old with a VSD/ASD on diuretics awaiting a determination of whether she would need surgical closure. My second patient was a one-year old girl with cognitive and physical developmental delay that we thought had the effects of kernicterus (she would need long-term physical and speech therapy, neither of which were available locally). The final patient was a 1 year old with breathing difficulty that we diagnosed with hypertrophied adenoids (I started her on nasal steroids and asked her to come back in one week to see Dr. Ramos so he could schedule her for surgery). I'm not sure who would do her adenoidectomy. There are no local ENT surgeons, but a general surgeon we met at Annotto Bay yesterday said that he does "some" pediatric surgeries.

Lessons learned:
1. Get kitchen scales to weigh diapers
2. Do teaching rounds with the local resident
3. Talk with Dr. Ramos about long-term availability of physical therapy.

Day 02 - Annotto Bay Hospital

Steve picked us up at the lobby at exactly 8AM. Since breakfast starts at 7:30AM, that gave us enough time to have breakfast and a few cups of the famous Jamaican Blue Mountain coffee. We filled our water bottles, which were provided by the resort and were waiting for us in our amazing suite/villa, with ice water, and were off on our one-and-a-half hour trip to Annotto Bay Hospital. This ride again took us down the same scenic route we took yesterday, but we passed Port Maria and traveled another half hour along the ocean.

Upon arrival to Annotto Bay hospital, it is difficult to imagine that this hospital was recently upgraded to a level B hospital. It is a group of small one-story buildings connected by a web of outside sidewalks that you find yourself sharing with goats, dogs, and chickens. We were received by the CEO of Annotto Bay hospital, a wonderfully charming lady named Ms. Mighty. In her office, we got a glimpse of the inner workings of administration. Communication is almost entirely by cellular phone. It is not uncommon for you to be having a conversation with someone and have them stop, mid conversation, and start talking on the cellphone. Calls appear to be business-related and are usually kept as short as possible. We quickly learned not to be offended if someone picks up their phone while we were talking with them.

Ms. Mighty contacted Dr. Melissa Fisher who came to greet us. She told us she was caught up in the pediatric wards because they had just received a set of triplets, each weighing a little over one pound. We (Dr. Fisher, Dr. McConkey, Diane, and I) were led to our clinic for the day. We were given the two nicest offices, the only ones with air conditioning, in which to work. Stacy set up her work space in one office, I left my stuff in the other and asked Dr. Fisher to take Diane and me to the pediatric ward where I could see if I could offer any help with the care of the triplets.

The ward is a single room, about ten-feet by 30-feet that is crammed with beds of several sizes, a few cribs, a few nonfunctioning incubators, and a nurses' desk. There is barely enough room for the beds and I'd find it very difficult to even walk around the beds. Luckily the infants were close to the entrance. They had been born about 5 hours before we arrived, and were estimated at 28 weeks - there had been no prenatal care and the gestational age was an estimate based on maturity rating.

Two infants were in an incubator, and one was in a crib. All were attached to a wonderfully simple, but functional, bubble CPAP system (see how it works here). The oxygen comes directly from tanks at the bedside, and there is no warning system in place to indicate low oxygen reserve. Someone has to check the gauge frequently, and bubble CPAP necessitates that the flow be turned up as the supply pressure drops. We were giving the infants CPAP at about +8 and they seemed to be breathing fine. The attached pulse oxymeters were reading 100%.

All of the infants were hypothermic with a temperature of 92-93F. None had an infant warmer in place. Diane asked Dr. Fisher about the warmers that Issa Trust had donated but Dr. Fisher did not know they even existed. Diane left to address this issue as Dr. Fisher and I tended to the infants. The nurses had wrapped the babies with several layers of insulation - one layer of 1-inch thick cotton, three blankets, saran wrap, and another blanket. The ambient temperature was close to 100F, yet an axillary thermometer read 92.6F. They were not monitoring internal temperature (they had neither probes nor a monitor), but were monitoring pulse oxymetry and heart rate. They did not have newborn size blood pressure cuffs.

I did not like having the babies wrapped to the point where I could not see them. If the babies were to survive, then these warmers that Issa Trust had donated only a few months ago were absolutely crucial. I examined all the infants - no heart murmurs, good air movement, no apnea. So if we could warm these infants up they had an excellent chance at survival. I unwrapped one infant and found that the inner cotton layer was soaked and so probably was doing more cooling than warming. I wrapped the baby directly with saran wrap, and then with a blanket. I layered some cotton above and then watched the temp gradually go up to 94F.

Diane arrived and told Dr. Fisher that she had found the warmers. The head matron (similar to our nurse manager) had received the donations and decided that the pediatric ward did not have enough space for them! Dr. Fisher was never even asked! That's when Dr. Fisher called the head matron and asked that two warmers be brought to the ward. I heard her having to argue with the head matron about space. The warmers arrived within minutes. They did not have any temperature probes so the babies' temperatures had to be manually checked every 10 minutes and then the warmers cycled on-and-off, but they were all normothermic within a couple of hours. Their heart rates stabilized, their breathing became less labored, and their mom was allowed to visit them. She asked if the hospital could inform the media about them - perhaps as a way to spread the word that she was going to need help with baby supplies.

I went back to our clinic site. I saw 5 patients in the clinic that day. Stacy had seen 12.

Lessons learned:
1. Inform the local doctors about the incoming donations
2. Get probes for the infant warmers
3. See if we can get newborn size blood pressure cuffs
4. See if we can get CPAP pressure monitoring systems

First Day - Port Maria Hospital

Our driver, Steve, picked us at promptly 8AM from the resort's lobby and we set off on our one-hour car ride to Port Maria. It is a breathtaking ride that I don't think I'll ever get tired of. During most of the trip you can see the ocean on your left, and homes on your right. Further to the right are often mountains covered in lush greenery. It is amazing how the wild trees that grow here bear coconuts, breadfruit, acai fruit, and even bananas. I asked Steve if there are many farmers that take advantage of the obviously fertile land and plentiful rain for farming, he said most farmers are concentrated more inland. Then he chuckled and said most of everything you would need on the shore grows wild! That's a little better than the weeds, poison ivy, and grass that I'm used to seeing in our "wild lands" (those around the highway).

The road is quite curvy, with several very acute turns, and for the most part single-lane each way. If you are the queasy type, you should probably take a dose of dramamine before setting off. The car will swerve quite close to trees, animals such as goats and dogs, and pedestrians but yet somehow always miss them. Steve is a great driver, but there were more than a few times where I wanted to close my eyes (but that would just make me more car-sick). So I just concentrated on the beautiful scenery, and I never ran out of things at which to marvel.

We arrived at Port Maria hospital one hour later. There was already a long line of people waiting to be seen, but at the clinic and at the "emergency room" office, which is probably better defined as the acute care clinic. I settled in a clinic office and my partner, Stacy McConkey, started to see patients in the acute care clinic. Each of us had a nurse assigned to us and she introduced herself. They were both extremely polite and brought us our patient dockets which we stacked in order on our desk.

My clinic room was rather comfortable. I didn't have an air conditioner, but I did have a fan. I sat at a desk on which I placed my computer and my equipment (stethoscope, otoscope, hand sanitizer, and water bottle). My first patient folder belonged to 5-year old Lashane. I poked my head out my door and said her name and she and her mom made there way inside. Lashane was the cutest girl who's mother had been taking her to several pediatricians trying to find an answer for what she thought were seizures. Local doctors were making her get tests done (an EEG, a head CT, several blood tests, etc.) all of which she had to pay for out-of-pocket. She became exasperated when a private doctor she went to asked her to pretty much repeat all of those tests. I suspect it was because he received some sort of kickback from the diagnostic laboratory. Don't get me wrong ... in the United States I would have probably sent for those same exact tests when presented with a 5-year-old with a history of "seizure-type events". However, when I dug deeper in the history, Lashane's mother reported no history of head trauma, drug use, or family history of seizures; Lashane had no aura-type symptoms, no post-ictal phase, and she was able to walk around when she was so-called "seizing". Deeper history revealed that she only gets these "events" when she is asleep. The events themselves are usually a sudden scream, followed by guttural sounds, and no response to commands. She would be nonresponsive to her mother but walked when led to the bathroom by her mother (who thought she might vomit). These symptoms sounded a lot less like seizures, but a lot more like night-terrors, a diagnosis I would have come to in the United States only after a head CT, head MRI, one or more EEGs, perhaps a sleep-study, and a variety of electrolyte and other blood tests. But night-terrors, academically, is a diagnosis that should be made by history alone.

Lashane was the first of 12 patients I saw that day. I saw four infants for well-child checks (one of whom needed a BCG vaccine, two of whom were brought by the mother's friend, so I couldn't get much of a history), one with pharyngitis, three with atopic dermatitis and/or rhinitis, another with tinea capitis, one follow-up for asthma, and two brothers with scabies. A good day!

I had about an hour between some patients when I could've had lunch. I had brought a banana and an apple with me, but I didn't really feel like eating. Those who need some mid-day sustenance would probably do well with a protein bar.

Lessons learned today:
1. For the ride - look at distant objects, or bring dramamine.
2. Take a VERY good history
3. Learn the differences in vaccinations. Infants here get BCG at birth.
4. Bring protein bars if needed.
5. Keep a personal supply of permethrin - you will see scabies and you'll need it for peace-of-mind.
6. ENJOY THE PRIVILEGE OF MAKING A DIFFERENCE!