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I am now at the end of my rotation, and it has been a good one. I have worked in many countries before, in many different contexts and capacities, and they are all different. What stands out about this particular site is the commitment from Issa Trust and Diane, and importantly from the Jamaican Ministry of Health to fill in the gaps of quality pediatric care. Ideally, of course, the rotation of doctors is a temporary measure, with the real goal of increasing the cadre of local medical personnel knowledgeable about pediatric care. The foundation attempts to do this through their lecture series, and I have heard the medical officers formulate plans based on what was learned from the most recent lecture. And while this is an amazing resource for those who can attend, the majority of children continue to be seen by medical officers who have not attended these sessions. In the absence of trained pediatricians, the medical officers working at the health centers and in the A/E would benefit from a “pediatrics for the general medical officer” curriculum. So for those to come, I highly recommend imbedding quick presentations for the A/E and health center staff on a regular basis. What has surprised me tremendously is the degree of medico-legal fear among practioners here. While we often think of resource limited settings being ones in which diagnostics are curtailed and clinical judgement emphasized, what I have found is that it is a bit of the opposite. I have ordered more labs here than I have in almost any other country in which I have worked. Of course, this only stands true for the routine patient. What is clearly lacking is the ability to make more complicated diagnoses. For instance, I admitted a 14 y/o girl last week who most probably has autoimmune hepatitis. I was able to get an Ultrasound, monitor her LFTs, but getting an ANA or other rheumatologic markers is nearly impossible. OK, now for the nitty-gritty: Resources I used most  over the month include Medscape, Harriet Lane, though mostly for the growth charts, and epocrates. A dermatology reference would have been helpful. I didn’t find a great need for any books dedicated to low-resource settings, for most resources are available in Jamaica (though the distance for travel is great, the cost is free). Nor did I find the need for any tropical medicine books. There is a canister of urine dipsticks at the villa that check for leukocytes and nitrites. The ones I’ve seen at the clinic are the ones used for pregnancy, focusing on glucose and protein. All the  places in which Issa works have on-site labs and so can always send the kid to the lab for a formal u/a as well. Turnaround time on x-rays is great, usually within the hour, or even half-hour, during the day. Most commonly encountered conditions: viral URI/ AGE, impetigo, eczema, seb derm, scabies. asthma, obesity in children (getting to be a big problem, and more commonly encountered than underweight), anemia. I’ve been treating everyone for worms per WHO guidelines. I have not seen anyone dispense zinc for diarrhea, and when I asked about it, I was given a blank stare. So again, think US practices and guidelines over WHO ones. Overall, it’s been great here, and I look forward to returning sometime soon.    
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Now that I’ve finally been here greater than a week, I feel I have more to contribute. I think this is an excellent rotation. Diane clearly cares for this work,for the country, for the patients, and to ensure this is a valuable rotation for the visiting pediatricians. There is a great deal of autonomy coupled with adequate local clinical personnel to answer questions. The medical officers are not trained in pediatrics, but most have significant experience working in this environment and are more than happy to assist/ answer questions. Having Dr. Ramos, the senior pediatrician, around greatly helps to bounce ideas off. The clinics themselves are quite busy, speaking to the need for pediatricians in this region. The medical officers are quite adept at caring for the basics of urgent care pediatrics along with well-child visits; however, they are uncomfortable with pathology or deviation from normal, making our role more appreciated. They are also quite eager to learn, so bring any presentations you may done! The living accommodations are superb. Everyone at the resort is friendly, knows us as the “Issa doctors” and goes out of their way to make us feel welcome. I am writing this as I sit along the beach listening to the waves, preparing to have dinner in the fancy Asian restaurant along the water. Can’t beat that!    
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I’ve only worked for 2 days, so this may be premature, but here are my very early observations: (1) Even in Ministry of Health hospitals, many of the medical officers are ex-pats, including Cubans, Burmese (!), and South Asians. It seems many Jamaican doctors emigrate to the US whenever the chance presents itself. Additionally, I am told the cost of medical education in Jamaica is quite high, further causing shortages in health providers. (2) I am surprised by how few “tropical” diseases there are here. For the most part, what I’ve encountered is not unlike what I see in the US: lots of viral URIs, AGEs, constipation, asthma, etc. (3) For good or for bad, practicing in Port Antonio or Annotto Bay is not too unlike practicing in low-income areas in the US. Here, limitations revolve around immediate access to diagnostics; in the US, limitations to treatment can be just as severe based on insurance status or ability to pay. (4) A nice change of pace from other parts of the world: Because of national health coverage, patients can actually get diagnostics and treatments, though they may have to travel 2+ hours to Kingston to do so… it’s uplifting to see after working in areas where even if a diagnostic test or treatment is available, unless payment is offered up front, the patient cannot access these. (5) It’s wonderful to have Dr. Ramos’, the pediatrician for the region, experience. He is practical and has a good sense of local epidemiology. So far, this is already proving to be a great experience. Will have more to report as time goes on.
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