Well it's time to start packing.  My time in Jamaica is drawing near to close.  Luckily I got to snorkel just once before the storm began 'again' today.  Tomorrow back in the air heading to Southern California where many things have been put on hold for two weeks ready to be attended to when I arrive.

Part of me is sad, I haven't been much help to the people here, or to the providers for that matter; though I saw as many children as I could, the parents and children still need more.  More time with the physicians to help them understand their child better, more accessible resources at low or no cost.  But I learned.  I learned people here still care about their patients and try to give them the best have and the best of themselves.  I learned that physicians use their own money at times to help patients get the interventions they need!

I learned that the Accident and Emergency department in Annotto Bay is expected to see more patients per day or they may have money taken away from them.  Which is hard to believe isn't it?  One of the last patients I happen to look in on who came into the A/E at Annotto Bay was a lady who had a previous Subarachnoid Hemorrhage, sent home, then told to follow up.  She didn't make it to her appt because she got a headache and began vomiting beforehand.  Her family brought her in as fast as they could, but she was unresponsive on arrival.  Wouldn't it be faster to have called an ambulance?  Nope, her daughter said that would have taken way too long.  As it was, Annotto Bay had to transfer this woman to Kingston because they can't even do a CT at Annotto Bay.  Talk about limitations.  Of course, what we take for granted in the US; 7 minutes response time for an emergency 911 call.  CTs and specialists to handle bleeding in the brain.  We would have the resources to possibly save this woman, but here she lives just too far away from the care she needed.  And then to have money taken from that system?  I hope those providers will be able to have a voice to help advocate for themselves and their hospital system.  I hope the people who understand the situation do too.  Ms. Meeks, thank you for all you do!

But overall, it was a good experience, I enjoyed seeing so many lovely newborns too.  Remember I told you they smile earlier than in the US?  You know what else?  It has been my experience in the US that babies allow a physician exam up to about 1 year and then they cry on exam because we are so invasive with tongue blades and etc.  But you know what?  I hardly had any 1 year olds cry with my exam, even with a tongue blade!  Simple things.  What is it?  The early socialization, the early care provided by many in the family or extended family?  I don't know, but it was a pleasant surprise that most children of all ages did not cry on my exam at all.  Maybe they were just taken aback by my very white skin! LOL! Whatever it was, it was such a pleasant thing to help in any tiny way to make some difference for just a day.

Many thanks to the physician team at Annotto Bay and Dr. Ramos.  Wish I could have been more helpful for you!  But I learned from you and I wish you all the best in your endeavors.  Thank you for all you do for your children!  You provide the best care even though you don't have all the fancy technology of an NICU!  Kids are resilient and they do well under your watchful eyes.

Take care all of you!   And to those at Issa Trust, my deepest appreciation for providing this lovely trip and experience!  Diane, my hat is off to you, thank you so much for all your advocacy efforts.  And Firas Rabi, thank you for all the work you have done with this blogI will look forward to working with you and Issa Trust in the future!

Traci Williams, MD

Port Maria was busy today, worked in the ED and saw a lot of stuff.  Remember the little girl with the potential UTI?  Her Mom did follow the advice given her and took her to the lab to get the work done and followed up today.  And lo and behold, she did have positive leukocytes.  So it's a good thing she followed through.  This is probably a case of the child wiping back to front, instead of front to back, so it probably does not need a further work up.  Just a little anticipatory guidance and all should be ok.

Then another boy stepped on a sewing needle that was on the floor, it broke off, and the sharp end was presumably still in his foot.  You could feel a foreign body, but you couldn't see it anywhere.  He was sent for xray and this story will be continued if he comes back tomorrow when I am there.  I don't really look forward to finding the needle in the haystack!

Another boy stepped on a nail and had a nasty abscess, he was none to pleased to have us touch that!  Let alone the tetanus shot he got, oh and the IV.  He had calmed down by then, and accepted his fate.  I don't think he really wants to follow up tomorrow with me, we will see if he does!

Stay tuned!

Suddenly it's day 5 and I don't know where the time went!  Annotto Bay.  Everyone was very nice and helpful!  Saw many little babies just born from a few days ago to a few weeks.  I love the babies, and I tell you, those babies are smiling before one month old!  Sooner I think than American babies!  Some babies in the US don't smile for 2 months, like my nephew for example!  But it seemed many of those babies were smiling at me and they were only 1 month old and even less.  Even some cooing from the barely 2-4 weeks old.  It's so nice to see that!  That means parental attachment and language acquisition has already begun in a good place.  So often times in the high risk population especially, those things like communication and attuned parenting is lacking.  We struggle to affect change in the lives of children, but we can't put back together the relationship very well.  And sometimes (more often than not) the success of treating the child is so dependent on the quality of the parent child relationship.  Costly in long term morbidities too.  But the early attachment, the early signs of social reciprocation of the parent child dyad is a comfort to the soul.  Brings a hope.

I know, sounds like a psychologist doesn't it?  Can't help myself.  As I treat more and more kids, the more I appreciate the importance of the relationship of the family and support it provides in child development of health and well being.  I know it really can be a challenge to take care of some of these complex kids!  Especially in a place where lack of resource is an all too common issue.  But when that nurturing supportive environment is in place for the child, prognosis is still good!  Children have that resilience.  Love to see that.

Saw one little girl who was accidently burned all over her face, scalp and chest with hot water.  Oh it was heart breaking to see all the facial color change and scabbing on the scalp.  But guess what, she was the most social child of the group in the peds ward!  She smiled at me and engaged in play with a teddy bear with me and she even would play and giggle to herself while she was not being attended.  So even though she has a terrific, horrific incident to recover from, her resilience was already in place.  Even though there will be some reminder physically for her always, as long as her support is stable, she will be just fine!

It's Day 3, 645am and I get a phone call that my driver is here.  Whew, was luckily almost ready anyway, but still a bit earlier than expected!  May have to do room service for tomorrow.  Crammed in some cereal and yogurt and off to Annotto Bay.  Met Dr. Ramos and Dr. Fisher and Dr. Blake and Dr. Ravi. They all asked me to send regards to all the ISSA doctors and nurses. Hey Firas Rabi, Dr. Ramos gives you a special high five! (he said you'd know what he meant).  They are all very nice!  They discussed some of the difficulties getting studies on the very tiniest babies in the "NICU"/Peds ward.  They ran out of pediatric culture bottles, so they go without getting blood cultures on the potentially critically ill babies.  Well I just happened to have the administrator of the hospital give me a ride home and I casually mentioned this issue.  I thought perhaps a little advocacy may be helpful.  She said she would look into it, I know she is very busy, but she appeared concerned and I hope follow up will take place.  Cross your fingers.  Yah mon.

As I took a tour of the facilities, I didn't realize Hurricane Sandy hit Jamaica pretty hard last year, especially Annotto Bay.  The Maternity Ward roof collapsed and damaged the building significantly.  They are now in recontruction of that ward and other places around the site.  Of course in the US, New Jersey, New York were also hit pretty hard by that Hurricane, billions of dollars of damage, etc, etc.  Wow, hurricanes really make for hardship long distances apart!

Day 2 Steve was right.  The driver said the people didn't know the doctor was here so they didn't come.  Well word got out through the grapevine I guess.  I was busy most of the day in the ED.  In fact the ED was filled with both adults and kids.  Most of it was the usual stuff, coughs and colds, wounds and abdominal pain.  Most of the parents switch to English for me, luckily, and then say something I can't understand to the child.  It's the doctors that are hard to understand LOL! For me anyway! 

One little boy came in and I heard him coughing in the waiting room.  It sounded like that tight asthmatic cough.  Luckily he came in early.....he was there all day.  Never had asthma his Mom said, she was surprised that his reaction was so severe.  He actually had to be admitted before I left, we couldn't clear him and he sat at 94% thoughout the day after several treatments.

Another little girl had a little burning "down there" and I had to send her to the lab because the dipsticks only check for protein and glucose......and then, the lab closed at 11am so we couldn't check for UTI!  Hope she can get it done.  Her mom said she had to work today and didn't want to take her out of school another day.  So another little medical drama.  What to do.  Treat her for UTI?  Or send her home with anticipatory guidance and lots of fluids?  You don't want to miss a UTI.  She wasn't wiping correctly so we gave her that info.  A few sitz baths perhaps?

Day 1 Port Maria, a beautiful coast line.  They call its location in "the country" compared to Kingston where the head doctor is from.....hard to get coverage there she says.  Too far away from civilization!  But the people were very nice.  Windy here and rainy yesterday, brings in the asthmatics.  A boy's teacher brought him in because he got short of breath in her class.  I thanked her for bringing him.....that wouldn't happen in CA where I'm from.  But for some reason that started an argument.  The doctor thought it was her duty to bring him.  The teacher said she wasn't supposed to bring him.....and on and on.  Oh well, no problem, as they say.  :) Day 1

Sunday Day 1 before Day 1!

Well here I am, ready to start working in Jamaica!  Took a minute to get here from Southern California, from a desert region to a lush green tropical area with a beautiful ocean!  Makes me wonder why I live where I do!  There was a thunder storm last night, but I barely noticed I was so tired.  Then to the River Falls where many people climbed the water falls!  I came dressed NOT to get wet, not knowing that the whole plan was to get totally wet.  So I stayed on the "mainland" until perhaps next week! :)

Mi a Go

I finished my last day of work, and it was bittersweet. According to my patient logs, I have helped many children here in Jamaica (135 to be exact), while enjoying the beauty of lush rainforest and gorgeous beaches.

The view from the bridge of Annotto Bay

On the way between Ochos Rios and Annotto Bay

Typical bar in Jamaica

On my last day, I saw a patient for the second time at Port Antonio Hospital.  She was a 12 year old girl who had come last week  concerned because she was always thirsty, and always urinating, even at night.  In fact, mom was concerned because this wonderful, active 12 year old had never had a dry night in her life.  The mother had brought up this issue in the past with previous doctors, but no one had quite figured it out.  I had them obtain some basic labwork and a urine sample.  She had normal kidney function, her urine was negative for protein or blood or sugar, and she could properly concentrate her urine (ruling out a hormonal problem that could cause this issue).  The last test that we did was to check her hemoglobin A1c, which reflects the amount of sugar in the blood present over the past three months.  Normal is less than 6.3%.  Hers was 8.1%, indicating that she had diabetes (likely type 1).  I explained what happens in diabetes, warning signs to look out for, and referred her to an endocrinology specialist at Bastamante Bay. 

What I will remember most is the gratitude on the mother's face because she finally knew what was wrong with her daughter.  The relief on my patient's face was even more gratifying.  When I first saw her last week, she was so embarrassed because she was twelve and was still wetting the bed at night.  She wouldn't make eye contact, and she barely said a word.  After she knew that it wasn't her fault, that a disease was why she couldn't keep dry at night, and that this problem was fixable once her diabetes was under control, she started smiling.

I have learned so much over this past month here in Jamaica, and am so sad that I will be leaving tomorrow. I have learned to be very self reliant, and this experience has shown me that I am ready (even if I didn't think I was) to take up the mantle of being a full time pediatrician starting in July.  I am comfortable with procedures, and managing sick and not so sick patients at the same time.  I realized how adaptable I can be, and I am able to utilize limited resources to coordinate care of a patient.  I am so much more comfortable now with the idea of striking out on my own. 

Of course, I had wonderful nursing and physician support to help me all along the way.  As I said before, the people here in Jamaica are amazing...especially the parents and patients themselves.  They are so respectful of doctors (everyone takes off heir shoes when laying down on the exam table), and very patient.  They will wait hours to see a doctor in the heat.

Waiting area at PMH in the morning

The waiting area at PMH in the afternoon

Here in Jamaica, they speak both Patois, which is a very lyrical language of shorthand English, slang, and French, and regular English.  During my time here, many parents would speak with thick accents in Patois.  Sometimes I would struggle with understanding them, other times they would struggle with understanding me.  However, they never became frustrated. One of the physicians at PAH (Port Antonio Hospital) even gave me a short half hour lecture on Patois, and some of the rules. Like, never say I, just mi.  Th is pronounced "da", and er becomes "a" like in "It ova dere".  Each region of Jamaica has their own dialect of Patois, which makes it even more fun. It was like a puzzle sometimes, as I would do my best to figure out what was said.


So, mi a go home. However, I will always carry this experience with me.   Heading outside to enjoy my last bit of sunshine before I go!

Waving goodbye!

All is quiet....until it's not

Yesterday, I worked at Port Maria's Accident and Emergency Department.  The morning was quiet, the calm before the storm.  I didn't have a single patient in the morning.  In the course of three hours during the afternoon, I admitted two patients and had to transfer one patient directly to Bastamante Hospital (three hours away) for emergent surgery. 

My first patient to be admitted was a 5 wk old baby boy who came in with fever and cough (likely with a cold).  However, because of his age and his immune system is not strong (and thus he is at risk for a serious bacterial infection), we had to admit him for IV antibiotics and check his blood and urine for infection. I obtained the labwork without problem, but the urine was another story.  In
Jamaica, it is routine to obtain urine specimens from children via suprapubic aspiration as opposed
to catheterization.  While it is the gold standard to obtain urine specimens this way, it is not routinely done in America.  Instead, we do urine catheterizations.  It was fascinating to see how this was done, and it seems surprisingly simple.  All you need is betadine, sterile needle and gloves, and a syringe.  You insert the needle directly into the bladder and draw back on the syringe to get the urine. 



The second patient I admitted was a very active 7 month old boy who had wriggled off his bed while
his mom was trying to change his diaper, and fell three feet onto a hard tiled floor.  He cried immediately, and was otherwise acting normally.  His exam was completely normal for his age except for a large bruise over his left forehead.  I admitted him for observation overnight.

The last patient was a 7 month old girl.  The moment the mom brought her in to the exam room, I knew something was wrong.  She was crying and whining nonstop, and nothing mom was doing was
helping.  Mom told me that she had started throwing up yesterday, and had become increasingly more
fussy overnight.  Yesterday, mom noticed that she had bright red blood in her diaper, and this
morning she noticed scarlet mucousy poop.  Her exam was notable for an increased heart rate, extreme tenderness over her entire belly, and guarding (trying to push my hands away).  Her diaper was filled with poop that looked like currant jelly.  I had never seen that before, but that sign is
pathognomonic for intussussception (the telescoping of one part of your bowel into another that can
cause death of the bowel if not repaired quickly). 





I spoke with the supervising ED doctor, who had never seen intussussception before. One of the
nurses had, and she confirmed that this was consistent with intussussception.  We called over
to Bastamante Bay Hospital, put in an IV and started IV fluids, and transferred her immediately
to the pediatric surgery service there (as there was none available at Port Maria).  Unfortunately,
Bastamante Bay is over 3 hrs from Port Maria Hospital, and is located in Kingston.



My day yesterday was very interesting, if not slightly terrifying.  I am so grateful for the help
that the ED doctor and the nurses here gave me as I was trying to take care of my patients without
knowing the system well or where things were. They patiently helped me out without making me feel
bad for not knowing.  I really appreciated that they did so, but I am not surprised.  Jamaican
people are amazingly warm, welcoming, and hospitable.  

Looking forward to what today will bring. 

Back to the Grindstone

Just kidding!  Currently, I am very sad that Kasey left Jamaica.  I really did enjoy spending time

with her, not only for her winning personality but because the exchange of ideas was excellent.  Since
we were from different parts of the country, we had our own ways of giving anticipatory guidance, or
managing certain illnesses.  We learned as much from each other as we have from the physicians in
Jamaica.  We also had a ton of fun together. 

Snorkeling with Kasey

 

This past Monday and Tuesday, I was at Port Maria Hospital, and I worked at their pediatric health care clinic.  Monday was a normal sick clinic, while Tuesday was a shot clinic.  Both days I saw 17 patients by 1:30 pm (approximately 4 patients/hr).  So, to recap, it was busy.  Some cases still stand out though. 

One patient, an 11 year old girl in middle school, came in complaining of pain behind her ankles
bilaterally and wrapping around the front lateral aspect of her foot.  She was an active soccer
player, who had been having this pain intermittently for the past two months (especially
when exercising a lot).  She also had some swelling around the lateral sides of her two feet, and
stated that her dad also had "bony bumps" like hers.  She had already had X rays of her feet, and
those were completely negative for any fracture, or tumor.  Her exam showed that she had tenderness
over the achilles tendon bilaterally and also over the point of insertion of the tendon into the bone
(lateral aspect of feet).  I diagnosed her with achilles tendonitis and accessory navicular bones. 
Treatment for this problem would include rest (minimize activity like soccer and walking) and
NSAIDs (ibuprofen).  However, when I told the mom this, she looked at me with dismay.  "She walks 2 miles to and from school everyday.  There's no way she can do that."  

I was reminded anew on how different Jamaica is from America.  Here in Jamaica, all children wear
uniforms to school, and those uniforms must be pressed & cleaned daily.  There is no such thing as
a bus system to take children to and from school, and I frequently see children walking on the side
of the road to school.  Some children even take taxis every day so that they can reach school. 
School here, while paid for by the government, is still a privilege. 

The other surprising patient that I had was an 18 mth old girl with chickenpox.  I had never seen
chickenpox before, and this rash was classic "dewdrops on a rose petal".  In Jamaica, the goverment provides vaccines for free, but not all vaccines are covered.  All vaccines that are available in the U.S. are available in Jamaica, but families must go to private pediatricians to obtain shots that are not covered by the government. The vaccines that are not covered include vaccines against Hepatitis A, Varicella (chickenpox), Meningococcus (can cause pneumonia and meningitis), Pneumococcus (can cause pneumonia and meningitis), and Human papilloma virus (causes genital warts and anal/cervical cancer). 

 

The chickenpox rash

Thursday, I met a wonderful 4 year old girl whose mom was worried because she was making a "chuffing" or throat clearing sound everyday, multiple times a day, for the past several weeks. Upon further history taking, I also found out that sometimes she would wring her mouth, or she would blink a lot. Each of these behaviors would last just a couple of seconds, and she would be completely aware throughout. She had done these behaviors for the past year. The little girl was otherwise completely normal. I diagnosed this girl with a tic disorder (? early Tourettes), and broke the news to mom that this disorder can unfortunately get worse (she can develop new tics), and that this might not be curable and medicine would not help. Mom was happy to have an answer, but unhappy that there wasn't much more we could do. Frequently, children who suffer from tic disorders can be taught behavioral techniques to help minimize how frequently they have tics. I don't know those techniques, and those that would (speech therapists) were not available. Here, speech therapists, along with psychiatrists and physical therapists are concentrated in bigger cities (like Kingston), with
a few scattered throughout the countryside. 

The more I learn about the Jamaican healthcare system, the more impressed I am at the doctors
here.  They truly rely on their clinical judgement, and are trained to be general practioners who can
take care of people from birth to death.  Many of them can also do surgeries like c-sections and
tubal ligations.  I like to think that during my time here, I have learned to be more decisive and
trust my clinical judgement from their example.

 

On the hillside of Annotto Bay Hospital

Let's start at the very beginning...it's a very good place to start!

I can't tell you how wonderful Jamaica has been so far!

I flew in on last Thursday, and started working this Monday on 4/14/13.  On Monday, Kasey and I shared a combined examination room at the Accident and Emergency Department at Port Maria Hospital.  We treated a ton of rashes that day (heat rash, papular urticaria, and tinea capitus).  I learned that when infants are taking Irish, they are actually eating mashed potatoes, and that "he du du" means pooping.   Good times.

Tuesday and Wednesday we enjoyed a wonderful drive to Annotto Bay (approximately 1 hr away from the hotel).   The coconut plantations were awesome, and the bay is breathtaking.  Outside the Annotto Bay Hospital, kids played soccer while a view of the Atlantic ocean stretched behind them.

Wednesday, we started off in the inpatient ward.  There were nine kids to round on.  The scariest part was that our sickest patient was a 4 yo male with sickle cell disease who had initially presented in vasoocclusive pain crisis in his back and abdomen, and subsequently developed acute chest syndrome.  In America, we would have this patient in the ICU and would probably be doing an exchange transfusion. Instead, the excellent nurses and doctors (guided by Dr. Ramos) were managing a very sick child on the ward, and doing a remarkable job with his pain control and fluid management.  I didn't know that in Jamaica there are only two pediatric ICU units, one in Kingston and one at University Hospitals.  Dr. Ravi pointed out how Dr. Firas Rabi had helped initiate a small ICU a few years ago. Most patients in their ICUs are on ventilators.  Luckily, our patient was maintaining his oxygen level on 4L via mask, and his pain was under good control with Morphine IV prn. 

Here I am, ready for sit down rounds with Dr. Ramos:   

In the afternoon, we headed over to the Accident & Emergency Department. I had the most interesting case, and 11 yo male who presented with R knee pain after a football (soccer) injury.  He was playing in his first game of soccer, jumped up to kick a ball, landed on his right leg, and another player collided with the front of his lower thigh.  He immediately felt pain, and was unable to bear weight or fully extend/flex his lower leg.  His exam was notable for swelling & tenderness around the lateral aspect of his R knee, his ligaments were intact, and he did have a positive McMurray sign (indicative of lateral meniscus tear).  We did X rays of his R knee, made him NPO, and gave him Voltarin IM (a medicine I wasn't familiar with, generic name diclofenac, an NSAID).  The X rays of his R knee revealed the surprise that Dr. Mitchell (ED doctor) had already predicted. He had an R femur fracture/epiphyseal lysis (a fracture of his thigh bone through his growth plate). I had NEVER seen something like that before!   We called the Orthopedic doctors and sent him to St. Ann's Bay.   

On Thursday, there was a well clinic at Annotto Bay.  Kasey and I enjoyed the plethora of adorable Jamaican babies who were primarily being seen at their two week and 1 mth check ups.   Both Kasey and |I were humbled by the trust that these parents placed in us...we wore stethoscopes, so we must be doctors.  We were able to give good anticipatory guidance about umbilical hernias, fevers, and no free water!

Thursday afternoon, we again went to the A&E department.  Kasey saw infantile dyschezia, while I saw a 15 year old F with diffuse abdominal pain (started periumbilically, and radiating to RLQ) concerning for possible appendicitis.  X rays of the abdomen were done and showed a nonobstructive bowel gas pattern.  I successfully obtained bloodwork, and started my first IV here in Jamaica!  When the IV fluids started dripping down the tubing, I knew the IV was good and I was proud.  In Jamaica, ED physicians regularly obtain their own bloodwork and start their own IVs.  However, in America it is very different.  I realized how lucky I am to have IV teams, scheduled phebotomists, or ED nurses willing to place IVs and obtain bloodwork.

Today we are at Port Antonio, and it rained this morning.  Kasey says that means that fewer patients will come.  We will have to see what happens next.   

I can't wait for what the next week will bring!

Post #132....P.S. Jamaica I love you

This has been a remarkable three week experience.  I am amazed, honored and humbled everyday when I put on my stethoscope.  Funny story from Rena's first day at Port Maria, there was a 5yo F w/ severe genu varum(bow legs) which had required surgical intervention with external fixation pins still in place.  She refused to believe that our fantastic Dr. Chandra was a doctor.  The reasons she listed were that her other doctors didn't have eyelashes or long hair, her mother simply corrected her by saying but "ah but she has a stethoscope."  The respect with which we are given by our patients, the staff, the nurses and other physicians by simply wearing our stethoscopes is humbling.  I am greeted with "Yes, doctor." Which is extraordinarily formal to me, but to decline would be disrespectful.  I accept it and work harder to earn the privilege.

I know I shouldn't pick favorites but I will likely always cherish my Annotto Bay experience the most.  Coming back for my third week, I am finally feeling familiar with my surroundings in both the pedi ward and the A&E.  I have been able to orient Rena to the general jist of our day to day activities, and I continue to watch our favorite 24wker grow.  She is doing fantastic, almost up to full feeds.  

In regard to the medicine side of things what I learn is heat + asthma= a full A&E experience.  I was able to care for a fantastic 13yo, who had instead of telling her family about her difficulty breathing been sleeping with her inhaler for the previous two days.  It was a good teaching moment of reviewing proper use of her inhaler, and why we shouldn't ignore the warning signs of an asthma attack.  It is clear that the dilemma of transitioning the care of adolescence with chronic diseases is an international weak spot. I think the most valuable things I bring with me on a daily basis are a)my brain b)stethoscope c)otoscope and d)portable pulse oximeter.  We just stumbled upon this delightful pulse oximeter which was hidden away in Rena's computer case, it has been key in my management of the various wheezers. 

Out at Port Antonio today, we met a Swedish pediatrician who was also visiting the region.  We were able to share our experiences.  I think our common theme is that here, or any third world, clinical skills direct management and he reiterated the value of a good physical exam.  The ability to share these experiences is just amazing.  My experience here has made me more thoughtful with my lab ordering and mindful of medication selection.  I will likely post again before I leave, but if I don't this has been phenomenal.  

P.S. Jamaica I love you

Where does the time go????

So living in paradise and working in the tropics is amazing!!! I have been here 12days now, and my adventure is starting to wind down :( but I plan on enjoying every bit of it.  Highlight of my week, there are many, but biggest is that I have a roommate!!! Yay Dr. Rena coming from Ohio to join the Issa fun.

I made it out to Port Maria this week on Monday.  I commandeered another corner of the A&E in the name of Paediatrics, saw a few sick visits but as it was a rainy day there was limited turnout.  What I did see was a pretty impressive L mandibular dental abscess which had been referred to the A&E from a local dentist.  I admitted her and started her on IV Augmentin, I attempted to use Clindamycin but there was none available.  The downside was that I knew that even once the antibiotics improved the inflammation, that she ultimately needed the tooth extraction.  This is a down point because access to dental care is even more limited than health care down here.  The happy ending is that when I returned to work on Tuesday, and visited her on the ward she was able to fully open her mouth and her pain was improved.  Though the ending is not ideal, I did make a difference.

Wednesday may be my favorite day of the week here.  The day starts with inpatient rounds, and the medicine is overall similar but the drugs of choices and incidence of drug resistance are worlds apart it seems.   There is always good discussion about Western trends in medicine and whether or not it is applicable herein Jamaica.   From there I wander down to the A&E.  It is always curious to me when the nurses ask me if I will see a child >12yo.  It was explained to me that their Pedi wards go from 0-12yo, but this limitation is due to the size of the beds.

Back down in the A&E my day was just about down when a frantic father brought in his 4yo son.  Seems the unfortunate little one was found at the other end of his sister's bucket and had been hit directly in the eye.  His conjunctival edema was so impressive that I was very worried about a conjunctival laceration.  We were able to refer him fairly quickly to Bastamante Children's to see ophthamology.  After this busy day I get to ride back along the countryside and watch the sunset as I rode.   Working in paradise, is a gift.


Working is great, but this is Jamaica we are talking about and I now have a fantastic partner in crime.  So far we've taken in tons of fantastic food, shopping and reggae dancing.  I look forward to the International Gala the resort is having tonight.   The setup looks fantastic and I am sure the food will be amazing as always! 

The view from Annotto Bay A&E

Port Antonio Paediatric Ward, about 10 beds and cribs in one large room.

Looking out at the island at the end of a long day...

Wait, Did we just drive over the Rio Grande???

Every morning I look to my left and there is the amazing Atlantic.  I am about one week into my rotation, and I've now been to the Annotto Bay and Port Antonio Hospitals.  The commute from the resort to Port Antonio is about two hours, I can't tell you for certain because I was completely distracted as we were driving through the rain forest.  Crazy lush foliage going up hills/mountains, crossing over the Rio Grande and the Atlantic Ocean is pretty much always just over your left shoulder. This is all in a day's commute.  Mr. Campbell,who is one of the adminstrators at Port Antonio, drove me on Friday I used this time during the commute to learn about the quality of life in Jamaica from education to shopping to roads. 

Once at Port Antonio, I had a chance to visit their Pedi Wards.  They are set up differently than ours in the US but they utilize what all of the resources are available.  There is definitely a need present.  Their facilities have relied on a lot of international donations, I am at total a 4hr flight from home and technically Hawaii or California is further but the difference in resources is night and day, Seeing how they are functioning on minimal resources(no code cart, limited number of nebulizer machines(like 2), no cardiac monitoring or unreliable pulse oximetry).   I never thought I'd actually be recommending the use of oral Albuterol, but the need forces your hand.  It forces you to rely on clinical judgment which I guess is why its the practice of medicine.

A common theme, seen both in the US and here in Jamaica, is the difficulty in chronic care management of our children with cerebral palsy and what to do when families become overburdened with their care.  I had a good discussion with Dr. Barrett about how best to optimize their care with simple interventions such as benzos and stretching to improve spasticity to increase their ease of care.  

Life back at Couples is fantastic, the staff is amazing.  It is the weekend, so I have tons of free time.  Between just enjoying the sun so far today I've been kayaking and sailing on a "Hobie" in the Atlantic.   I am pacing myself because all of these water adventures occur between delicious meal times and sunbathing.  Well cocoa bread is calling me and there is still some sun left, I will tell you guys more later. 

I've arrived!!!(is it too early to start planning my trip back??)

To say it is beautiful here is a gross understatement.  The land, the water and the people have eased my transition into life on this amazing island. I know my predecessors have mentioned the amazing scenic views on the way to work, but I was still awestruck.  There is something fantastic about living and working within walking distance to the Atlantic.

I started out my adventure at the Annoto Bay Hospital on the inpatient ward. I was intrigued and impressed to see the team caring for a former 24wk infant( rocking out on bubble CPAP alone!!!) who was continuing to beat odds on a daily basis.  It was good opportunity to use my prior NICU experience to add additional insight, but I was reminded how spoiled I am back home with what seems like limitless resources. Here they've two incubators, and no ventilators at this facility with only limited numbers at other hospitals.  The care they provide here relies on clinical expertise.  I feel I both have much to give and so much to learn at the same time.

From the inpatient wards I wandered down to the A&E with Dr(s). Mitchell and Espinosa who also welcomed me with open arms, which translates to happily tolerated my frequent questions and requests for translations.  There I was able to see the variety of sick children who came in whose illnesses ranged from viral gastroenteritis to seizures.  The pharmaceutical trade names here are totally different, also your repertoire is limited to what is easily available to these patients.  Ever heard of Lucozade? Me either but between the patients and the other physicians they helped me figure it out, overall I had a great first day.  I can’t wait for day two!!!

Last day....

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

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

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

 Later that afternoon we went on the Catamaran cruise (our 4th time...we know, a little excessive) but we love the crew and the peacefulness off being out on the ocean. Plus we met some great people this time who were spending their anniversary here and had some great conversation. The waves were a little crazy and Stephanie and I had a few scares sitting on the front of the boat (I lost my prized blue aviator sunglasses!!) but all in all it was a great time. I found myself in a back flipping competition off the boat with one of the staff, Odain, and I like to think I won. He was much more fearless than me though and his one foot back flip was a crowd pleaser. After returning back to the resort, we participated in a Reggae Dance class on the beach. I'm sure we provided great entertainment and a lot of laughing for those watching. We again had a great dinner and ended our night by skyping our fellow 2nd year residents. This weekend was our annual retreat and we were sad to miss it but we like to think we were there in spirit. After much laughing and telling them about our experiences here we hit the sack looking forward to our last weekend day on the resort.

We woke up Sunday and climbed Dunn's River. We had both done this before, Stephanie 6 years ago on a cruise and me on my honeymoon 4 years ago, but we were up for a 2nd trip. The sun was out and we again
were feeling adventurous. Our bus driver, Gary, had to be one of the funniest people I've ever encountered. He gave us a full tour of Jamaica on our way to the falls telling us about everything we passed from an Electric Store with the motto "stronger for longer" (you can imagine the jokes made) to the only radio station on this side of the island called 'Irie' which plays only reggae music. He then gave us a run down of the geography of Jamaica, explaining that we had passed through 4 parishes from the airport to the resort which resides in St. Mary (interesting fact is that Port Maria where we work Monday and Tuesday is the capital of St. Mary). We arrived at Dunn's River and after very strict instructions from Gary regarding vendors and video purchasing we were off. It was a great group of people from the resort and we had an absolute blast. Walking hand in hand with a bunch of strangers up a waterfall doesn't sound like the safest thing but we were taken care of by our guides and each other. From falling backwards into the water to going down a natural slide made in the rocks we were smiling the entire time. We don't have pictures because we forgot to bring a waterproof camera but it was beautiful and a great time overall! We got back to the resort and spent the rest of the afternoon relaxing in the sun and making tie-dye shirts!!! I was much more excited than Stephanie as tie-dying has long been a passion of mine, just playing, kind of.  We made late afternoon spa appointments for a facial and pedicure, both of which were wonderful and a must if you get time. By the end we were so relaxed and thankful for the much needed pampering. We then headed to dinner and like always the food was amazing. We also met this great couple who were on their 13th trip to this resort and had a son in his 2nd year of medical school!! We had great conversation with them and ended the dinner stuffed!

                      

 

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

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

Our last drive home from work was gorgeous like always. After you get out of the town of Port Maria it's just ocean for a few kilometers and it's breathtaking. Nothing can ever beat it.

Tonight were packing (and maybe crying) as we prepare to leave in the morning. We can't believe it's already over. We're planning on going to the beach party tonight followed by Margaritaville with the rest of the resort-goers :) it should be a great ending to a wonderful trip!

Fully blessed and sad to leave,
S&S

Is it really almost over???

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

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

 

  

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

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

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

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

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

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

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

Still feeling so blessed,
S&S