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Ok, so my flight was cancelled and I got an extra beautiful day in Jamaica. How awesome is that!

So this is likely my last blog. My last week was short but still great. Monday was Easter Monday, a holiday, and Friday I got the day off to finish and do any last minute things before I left.

On Tuesday, I saw about 30 kids. It was like the post holiday/school’s out rush as the week before there were only about 20. Tuesdays at Port Maria clinic has been the busiest days this month. You average about 25 patients. David and I figured out that maybe on those days we should both go to the clinic so that people who are there from 8am aren’t getting too upset when they are still there at 3pm being seen.

The picture above (taken with permission from Mom) is of a little girl I saw twice this month. Initially she came in for recurrent oral thrush and a neck rash that looked like tinea versicolor. She was on the appropriate medications and mom was using it correctly so I was a little curious as to why it hadn’t been getting better. I asked mom about her history (was worried about maybe some immunodeficiency, HIV etc) and sent her to get a CBC. Of course blood work wasn’t being done that day so mom was suppose to come back to see me once she got the results and to continue using the medication.

As is obvious in the picture, this child also had a large head. She had already been sent to have a head ultrasound for hydrocephalus, even though there had been no documented hydrocephalus or even head circumference in the chart…EVER. Mom reported that the ultrasound was normal.

On Tuesday, mom returned with the CBC results and a bottle of medicine that she said the child had been on daily since January for a vaginal discharge. It was Septra. This baby had been on antibiotics since January for what it didn’t sound like was a UTI or any type of VUR; The reason for the continual use was nothing more than a miscommunication. Mom was told to give the medication until it was finished (something we may say to our patients if we wrote a prescription for a specific amount). Unfortunately, she was given a large bottle of the medication and it was not finished. Her CBC was not grossly abnormal except for a slight anemia but I felt I knew the culprit for the recurrent thrush (I hope). So I had mom discontinue the antibiotics and return in 1-2 weeks.

I also did a head circumference and would like her to have serial head checks because unfortunately mom cannot afford a CT scan right away. I do not feel that this child’s head is normal and fear that it will progress until she starts having sunsetting of her eyes (they are, as is obvious in the pic, already large and somewhat bulging). She is currently developmentally normal and a delightful child. Because this was weighing so heavily on my mind I asked the pediatrician at Annotto Bay on Wednesday what he would do. He recommended just referring her to Neurosurgery in Kingston and letting them sort out imaging. Great advice! I would never do that at home because for a referral to neurosurgery I would likely need imaging to prove that a neurosurgical problem exists and not just a referral for macrosomia. Would like to know that this baby continues to do well.

On Wednesday and Thursday we saw a lot fewer patients at Annotto Bay than usual. We finished both days a little early and were excited that we may get to return to the hotel earlier to do some activities if possible; That didn’t happen. On Wednesday, we had a detour to the garage the hospitals use to work on the vehicle’s brakes (pic above is the garage). On Thursday, our transportation that the hospital arranged for us was in Kingston and we ended up waiting for about 3 hours since they had delays getting back.

My final thought: Many of the problems here in Jamaica with health care stem from lack of resources. As you read blogs you hear about a hospital with no mechanical ventilators, makeshift CPAP, no sub specialists, labs that cannot do urinalyses, clinics not equipped for pelvic exams. They are all needed but aren’t things that we can readily provide. However, there is one area I feel that we can leave an imprint in addition to our service. At Port Maria, the only vital taken is a weight. There are growth charts up to the age of 2 with only weight on SOME of the charts. I did not see them in the charts at Annotto Bay or Port Antonio BUT at Annotto Bay, all vitals incl temp are done and we were provided a copy of full growth charts (birth to 20, females and boys, wt, length and HC).

Maybe we can work to integrate full growth charts in EVERY chart as well as encourage full measurements incl temp, BP (age over 3 and would require they have the appropriate BP cuffs), HC, RR and weight. By doing this we could pick up the infants like the one admitted at Annotto Bay with meningitis at all the centers (the infant was clinically normal, mom came for well infant/newborn check and this was only identified because of a fever documented in clinic). We could avoid things like referral for 2 children who ‘look thin with ribs showing’ when they are growing well (50-75th percentile) and likely having more rapid height gain and from missing children that are failure to thrive because they have not been plotted in their last few visits. This is just my 2 cents and hope that maybe we can accomplish that.

Thanks again to Diane and Couples resort/Issa Trust Foundation for an amazing experience.

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So I have somewhat of a potpourri of things to write so I will probably break it down into 2 blogs…one patient related and one not so much.
As I looked back on my month I have been super blessed for this opportunity. I thank Diane and the trust for it.
Things might be helpful for the next group:
1.PLEASE MAKE sure you walk with toilet paper and something to dry your hands. Some of the bathrooms are equipped with toilet paper, most dont have anything to dry your hands.
2. If you are a light sleeper walk with ear plugs….if you are not use to the island sleeping there are crickets and frogs that chirp all night (for most you just drown it out). Also, if you are in the inside room its a little closer to the road so you may hear an 18 wheeler trucking by once in a while (none of these are problems if you arent too light of a sleeper)
3. If you are in the clinic and you want to admit a child you refer them to A&E (ED) department!
4. There are 2 types of referral forms…an interfacility referral white form (form B) and a triplicate copied referral BOOK for outside referrals (i.e all pediatric specialists, most of which will be in Kingston at Bustamante Children’s ; this is referral form A)
5. You can get laundry at the resort done without cost ( I washed many small items in my room
and then big things with the resort)
6. Get familiar with the drugs and their concentrations..Qvar inhaled spray I think is 100mcg, I had never used chloramphenicol eye or ear drops and it was not found in any epocrates so I had no idea the dosage initially. Same goes for their analgesics. DPH cough medicine IS diphenydramine as well as a plain DPH is benadryl then there is DPH cold that would have an expectorant in addition to benadryl. It is widely used for colds from birth onward.
7. Pediatrics is anything under 13 yrs old. All the children older than that stay on the adult floors/wards.
8. Vitals arent very common at Port Maria. They do a good job at Annotto bay but you only get a weight at Port Maria.
9. If possible do tours outside of the resort. IF you are adventurous the zip line and boblsed ride is fun. There is a blue mountain bicycle tour as well as some rafting tours. I enjoyed Dunn’s River falls.
Hope this is helpful
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This blog is LONG overdue. As the last week rolls around its only fitting that I write SOMETHING.
For the last 2 weeks I have to say that many of the patients seen have similar ailments as you would see in the US except probably alot more tineas. However, there has been a few cases thrown in that were interesting.
On one of the days we rounded with the pediatric team, we had a 9 year old boy who came in after having his first time seizure the evening before. Per reports the seizure happened during his sleep. Its funny I got a slightly different story from the boy (I’m thinking the way I phrased my questions probably werent the best). Anyway the going diagnosis was possible benign rolandic epilepsy. It’s the right age group and description but of course without the EEG available it is something that will need more occurrences before a firm diagnosis is made.
In the clinic we also saw an infant with diffuse papular lesions on his face and extremities. The infant was very uncomfortable and scratching. Dr Ramos, one of the pediatricians, called us in to see the infant and asked what we thought. It really looked like maybe a scabies type infestation but more papular. He described it as a papular urticaria seen in response to insect bites. It made so much sense as he pointed out that the lesions were only in the areas that were uncovered when the infant slept. I have seen insect bites but never a reaction so widespread before. It was great to have someone show us things that may not be as prevalent at home.
There is one other case, more unfortunate than anything else but may help any one else who encounters a similar case and don’t know how to proceed. I saw a 12 year old girl in the clinic with her mom. Per mom she had been complaining of vaginal itching, foul odor and ‘bumps’ for about 3 days or so. She did tell mom that she had her first sexual encounter with a 16 or 17 year old boy although he didnt ‘go all the way in’. Turns out she had what appeared to be primary herpes outbreak. At home we would call our Child Assessment team and they would get right on it since the girl is a minor (under 16 here). However I was not sure how the system worked or who to inform and it became somewhat frustrating since I did not know the protocol. However, I got in touch with the Child and Mental Health nurse and the matron who assisted me in the protocol—–in essence you refer the child to the A&E department (Emergency room) where the hospital’s social worker and the assault division of the police department can get all the information and deal with the case. Its imperative to get all that information and sometimes even admit the child for observation to obtain these things because most houses dont have addresses like we do in the US and also most families do not have phones. So for fear of the family disappearing (not intentionally) you may have to admit a child just to get all information sorted and proper treatment.
On a lighter note, we were able to have extra time off this week for Easter (both Good Friday and Easter Monday are holidays). I was able to go Mystic Mountain and try the bobsled rides as well as the zip line…it was fun! If anyone comes for Easter, you can show how much you know about Jamaican culture by mentioning ‘bun and cheese’; this is a tradition that involves eating a ‘bun’ (looks like fruit cake) with cheese in the center for Good Friday. The resort had some as desserts so David, my coworker, was able to try it.
I must say that everyone I have encountered have been so warm and welcoming. I feel I have inherited a new family of sorts with the workers here. It saddens me that I soon have to leave.
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So we had our last 2 days in Port Maria. Since it is 2 of us we usually split up with one going to A&E and one in the clinic. However, on Monday the medical records department are striking (this was a surprise to everyone working there) and so we both were asked to go to the clinic since they were short staffed in A&E.
We saw alot of rashes including a pityriasis and likely lichen striatus that David saw (he got the cool stuff).
Today, I went to A&E and David managed the peds clinic. I took some toys to the pedi ward and it was like water in a desert! Everyone including some staff wanted to grab toys for their children. All of the ‘play’ areas are devoid of toys or anything for the children to play with and I now can see how appreciative they are. I’m not sure how long those toys will actually last on the ward but at least I know temporarily they have something to play with.
Over the last few days i’ve picked up some lingo I figure I might share. When they say they are rattling in their stomach….stomach actually means chest and belly is stomach.
Today was the first I heard that a child had ‘short wind’ aka rapid respirations or shortness of breath.
Clinic was very busy today…I think there may have been about 30+ patients because David saw I guess around 23-25 and I picked up another 5-7 at the end when I got through with A&E.
Saw a few URIs, overfeeding, scabies, laceration on the face (felt absolutely awful while suturing this kids wound because the sutures available were 0 to 2.0 with HUGE needles!!), pharyngitis and overflow incontinence, more scabies, eczema, constipation, wheezing and asthma follow ups.
Off to Annotto Bay tomorrow.
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Hi all,
I am also a resident from the University of Tennessee. I am 4th year Med/Peds. I am SO Blessed to have this opportunity to come and work with the people of Jamaica. It has already been quite a week.
I had a rocky start getting here with delayed flights and lost luggage. It was a good thing I came a few days before starting work. It is absolutely calming and tranquil here and the people at the resort are very welcoming and accommodating. The food is plentiful, to be modest, and I now feel I have to work out twice a day on weekends.
We spent our first 2 days in Port Maria, the next 2 in Annotto Bay and the last day in Port Antonio. At Port Maria for the first 2 days I worked in the Health Clinic.
I saw the general run of the mill cases like viral illnesses, lots of tineas, candidal vulvovaginitis and complaints of worms. Many of the parents expected medications for their children’s ‘chest colds’. Down here cough medicine is DPH and that’s not a brand name. It is actually Diphenhydramine. I spent some time educating the families on the ineffectiveness and detrimental effects of cough medicines. Most were receptive, a few didn’t seem too happy.
The first day I saw about 16 patients, which was hard because I had to stop every minute to ask how things were done and what was available. The second day I saw 25 kids. In our residency, we never get to see that many in our continuity clinics because you have to check out to a superior etc so I was amazed that I could see that many in 6 hrs. I had a few pneumonias and a teenager who came in for many different complaints including vulvovaginitis, anxiety attacks and irregular menses. My interesting case of the day was a set of siblings who came in for generalized itching for 3 weeks after they were swimming in a river. I was SO out of my element because that differential is broader with tropical diseases esp ones transmitted from river water. They do have leptospirosis down here but the symptomology was no where close to that. Could it be schistosomiasis, or some other parasitic infection? I treated them as best I could and recommended they returned if things worsen or did not improve.
At Annotto bay I worked in the A&E department one day and the clinic the next. The clinic was mainly well child visits. It appears that about 3-6 weeks after birth the children are seen by a physician for an examination. After that they receive their “well child checks” at the health clinics with nurses and thereafter see a physician if they are ill. This is unlike our American system where the physicians are the ones doing the Well child visits.
You also are required to draw your own labs and start your own IVs. So far the children here have been spared from me but I do look forward to maybe perfecting those crafts. The most interesting child I saw at the A&E was a referral for a possible glomerulonephritis. The patient had no previous illnesses but was noted to have swollen legs and face prior to admission. I was very excited about working the child up and reaching a diagnosis, however many of the labs such as complement levels, renal ultrasound and maybe urine electrolytes were not available at that hospital.
At Port Antonio, it was a very light day with only 4 children on the ward and 6 total in the clinic (3 seen each by David and I). Two of my 3 cases were referrals for orthopedic issues that I unfortunately could not help. One was a beautiful 4 month old with club feet. The parents do not have the transportation available to get to the referral hospital. I hope they find a way because I am sure with braces she will correct well. In the meantime I tried to recommend a temporary way to get her feet to straighten by recommending buying stiff shoes that ae a direct fit.
While we were on a tour of the facilities (Port Antonio sits on a hill overlooking a lagoon) we got called into A&E to look at a chest xray of an 18month old boy who at a glance looked quite well. The xray looked like he had a whited out R lung with a mediastinal shift to the right and elevation of his right hemidiaphragm…looked like a possible foreign body aspiration. He had to be transferred to Kingston. He was still out in the yard of the hospital playing when we left, definitely in no distress and a little bit of a lady’s man already.
All in all this week identified the biggest obstacle to care in the area….resources. There are few physicians and few resources available to a poorer population that arent able to travel very far for optimal care. I’m looking forward to what the remaining weeks will bring.
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