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!!

Day 1 at Porto Maria for Stephanie and Chris

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

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

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

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

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

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

Black Dressing

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