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