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.