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 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.

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!