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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.
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The clinics are closed and it is time to rest. It is difficult not to enjoy yourself while you are here. The all-inclusive part of the resort includes almost all water sports. Scuba diving lessons and dive are everyday at 9AM. A bus departs everyday but Friday to the beautiful Dunn’s River Falls, Jamaica’s most famous waterfalls. You can go water skiing or knee boarding. Sailboating, kayaking, and pedal boating are all included. Couples’ employees designated as Entertainment Managers arrange for daily activities such as sand and pool volleyball. And there are three different pools to lounge by, one of which has a swim-up bar.

I thought I would feel out of place being here by myself among guests that have all arrived as couples, but the group activities are geared to letting everyone get in on the action. When I sit by myself for meals, almost invariably one of the employees sits with me and we have a nice chat. It’s been a few days and almost all of them know why I am here. They treat me with much respect and are eager to make my stay as comfortable as possible. One favorite greeting, “Respect”, pretty much says it all.

Respect!
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Port Antonio is a two-hour ride away from the Couples Resort at Tower Isle. I still love watching the scenery during our ride. But anyone prone to carsickness should definitely premedicate with dramamine. The road is extremely curvy and the long ride is a good setup for some unpleasant feelings.

Port Antonio hospital is designated a type-C hospital – that is the lowest level of care. However, the buildings themselves actually look to be in better shape that both of the other clinics we’ve been to. Dr. Ramos, our partner Jamaican pediatrician, indicated that this location is in the most dire need of pediatric services.

Our contact here was Dr. Davis – she is a gynecologist. She introduced us to two other physicians, one of whom was Dr. Fazul. She called him a resident but he has been at the hospital for 6 or 7 years. I wanted to understand this more, but I figured that is a question I can ask later. Dr. Fazul was going to go to do inpatient rounds and we (Stacy and I) went along. There were 5 patients – two first-time wheezer infants (neither of whom had a pulse oximeter), a 5 year old girl with gastroenteritis (she was getting fluids – D5 0.45%NS – but without an IV pump), and a newborn who had been born at home and was being treated for presumed sepsis. There is no mechanism for local microbiology, so cultures have to be sent to Kingston (two hours away). Cultures are usually bundled to be sent on one particular day. Dr. Fazul expressed his frustration that even on the days the cultures were supposed to be sent out, often weather would impede or even cancel the transport. He therefor rarely obtains cultures, and treats empirically. In this case, the home-born infant who was otherwise doing well was going to be receiving cephalosporins for a week.

The fifth child was a 1 year old who had been admitted a few hours before we arrived. He had been reaching up to a pot of boiling tea and it toppled on him, scalding most of his right side. I estimated his burn at 15-20% of mostly third-degree burns. Needless to say he was in obvious discomfort. They were managing his pain with oral paracetamol, the equivalent of our tylenol. It was woefully inadequate. The child did not have an IV and was not receiving any IV fluids. He was at risk for significant fluid loss. The best way to monitor fluid status is by closely observing the urine output. They had no way of weighing his diapers as a method of monitoring his urine output. A $20 kitchen scale would solve this.

I asked them about morphine, but they were hesitant to use it. I gave them a dose to use and the nurse set about getting it. Since they have no respiratory monitors they were understandable worried about respiratory depression. However, as Stacy quickly pointed out to them, a child in that much discomfort would not likely  fall asleep from a minimal dose of morphine. There was a little “teaching moment” here – infants with burns are more likely to die from fluid loss than they are from infections. I ordered some fluids and let them know that he should have a full wet diaper every two hours.

Stacy and I went to our clinic after rounds. This was by far the most comfortable clinic we’ve had in the past three days. A fully air-conditioned room, with a nearby sink and refrigerator. This clinic sees patient on an appointment basis. I was scheduled to see three patients. We’ve been trying to get the word out that the pediatric clinic would be staffed on Fridays, and with time we will have more patients. Right now, most people are still used to only having the pediatrician, Dr. Ramos, available on Tuesdays.

My first patient was an 8 month old with a VSD/ASD on diuretics awaiting a determination of whether she would need surgical closure. My second patient was a one-year old girl with cognitive and physical developmental delay that we thought had the effects of kernicterus (she would need long-term physical and speech therapy, neither of which were available locally). The final patient was a 1 year old with breathing difficulty that we diagnosed with hypertrophied adenoids (I started her on nasal steroids and asked her to come back in one week to see Dr. Ramos so he could schedule her for surgery). I’m not sure who would do her adenoidectomy. There are no local ENT surgeons, but a general surgeon we met at Annotto Bay yesterday said that he does “some” pediatric surgeries.

Lessons learned:
1. Get kitchen scales to weigh diapers
2. Do teaching rounds with the local resident
3. Talk with Dr. Ramos about long-term availability of physical therapy.
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Steve picked us up at the lobby at exactly 8AM. Since breakfast starts at 7:30AM, that gave us enough time to have breakfast and a few cups of the famous Jamaican Blue Mountain coffee. We filled our water bottles, which were provided by the resort and were waiting for us in our amazing suite/villa, with ice water, and were off on our one-and-a-half hour trip to Annotto Bay Hospital. This ride again took us down the same scenic route we took yesterday, but we passed Port Maria and traveled another half hour along the ocean.

Upon arrival to Annotto Bay hospital, it is difficult to imagine that this hospital was recently upgraded to a level B hospital. It is a group of small one-story buildings connected by a web of outside sidewalks that you find yourself sharing with goats, dogs, and chickens. We were received by the CEO of Annotto Bay hospital, a wonderfully charming lady named Ms. Mighty. In her office, we got a glimpse of the inner workings of administration. Communication is almost entirely by cellular phone. It is not uncommon for you to be having a conversation with someone and have them stop, mid conversation, and start talking on the cellphone. Calls appear to be business-related and are usually kept as short as possible. We quickly learned not to be offended if someone picks up their phone while we were talking with them.

Ms. Mighty contacted Dr. Melissa Fisher who came to greet us. She told us she was caught up in the pediatric wards because they had just received a set of triplets, each weighing a little over one pound. We (Dr. Fisher, Dr. McConkey, Diane, and I) were led to our clinic for the day. We were given the two nicest offices, the only ones with air conditioning, in which to work. Stacy set up her work space in one office, I left my stuff in the other and asked Dr. Fisher to take Diane and me to the pediatric ward where I could see if I could offer any help with the care of the triplets.

The ward is a single room, about ten-feet by 30-feet that is crammed with beds of several sizes, a few cribs, a few nonfunctioning incubators, and a nurses’ desk. There is barely enough room for the beds and I’d find it very difficult to even walk around the beds. Luckily the infants were close to the entrance. They had been born about 5 hours before we arrived, and were estimated at 28 weeks – there had been no prenatal care and the gestational age was an estimate based on maturity rating.

Two infants were in an incubator, and one was in a crib. All were attached to a wonderfully simple, but functional, bubble CPAP system (see how it works here). The oxygen comes directly from tanks at the bedside, and there is no warning system in place to indicate low oxygen reserve. Someone has to check the gauge frequently, and bubble CPAP necessitates that the flow be turned up as the supply pressure drops. We were giving the infants CPAP at about +8 and they seemed to be breathing fine. The attached pulse oxymeters were reading 100%.

All of the infants were hypothermic with a temperature of 92-93F. None had an infant warmer in place. Diane asked Dr. Fisher about the warmers that Issa Trust had donated but Dr. Fisher did not know they even existed. Diane left to address this issue as Dr. Fisher and I tended to the infants. The nurses had wrapped the babies with several layers of insulation – one layer of 1-inch thick cotton, three blankets, saran wrap, and another blanket. The ambient temperature was close to 100F, yet an axillary thermometer read 92.6F. They were not monitoring internal temperature (they had neither probes nor a monitor), but were monitoring pulse oxymetry and heart rate. They did not have newborn size blood pressure cuffs.

I did not like having the babies wrapped to the point where I could not see them. If the babies were to survive, then these warmers that Issa Trust had donated only a few months ago were absolutely crucial. I examined all the infants – no heart murmurs, good air movement, no apnea. So if we could warm these infants up they had an excellent chance at survival. I unwrapped one infant and found that the inner cotton layer was soaked and so probably was doing more cooling than warming. I wrapped the baby directly with saran wrap, and then with a blanket. I layered some cotton above and then watched the temp gradually go up to 94F.

Diane arrived and told Dr. Fisher that she had found the warmers. The head matron (similar to our nurse manager) had received the donations and decided that the pediatric ward did not have enough space for them! Dr. Fisher was never even asked! That’s when Dr. Fisher called the head matron and asked that two warmers be brought to the ward. I heard her having to argue with the head matron about space. The warmers arrived within minutes. They did not have any temperature probes so the babies’ temperatures had to be manually checked every 10 minutes and then the warmers cycled on-and-off, but they were all normothermic within a couple of hours. Their heart rates stabilized, their breathing became less labored, and their mom was allowed to visit them. She asked if the hospital could inform the media about them – perhaps as a way to spread the word that she was going to need help with baby supplies.

I went back to our clinic site. I saw 5 patients in the clinic that day. Stacy had seen 12.

Lessons learned:
1. Inform the local doctors about the incoming donations
2. Get probes for the infant warmers
3. See if we can get newborn size blood pressure cuffs
4. See if we can get CPAP pressure monitoring systems
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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!
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