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It’s my last night in Jamaica, and I have had a great two weeks working here!  I have learned a lot about the medical system here in Jamaica and have seen a lot of patients!  I’ll give a quick run down of the way my weeks were set up, followed by some things that I enjoyed most about the resort, and finally some helpful cultural/medical tips that are different from how things typically go at home!

Monday/Tuesday: Port Maria
This is a rural hospital and is the closest of the three locations.  ~ 30minutes by car.  My day typically went from ~8am-4pm, occasionally finishing a little sooner.  I spent a little bit of time up in the ward, but mostly I worked in a room right around the corner from the A&E (Accident and Emergency) seeing patients (mostly patients from the A&E but sometimes also patients that were being seen for immunizations in the outpatient setting that nursing also thought could benefit from seeing a doctor).  Sometimes it was a little slow at the very beginning of the day, but it always picked up and then there was never a lack of patients to be seen before the end of the day.  I probably saw ~10-20 patients per day.  The volume here was definitely a plus.  One of the general doctors was staffing the A&E, which was definitely a benefit because especially at the beginning, I had questions about what medications were available in the pharmacy, how to get someone referred to get a hearing test, get an echo, or see a subspecialist.  I think that is one of the more challenging aspects of the trip– just figuring out how to navigate the healthcare system here.  The general doctors in the A&E were very helpful.  Sometimes with the volume of patients, it would take some time to find someone to get the answer that I needed for the patient.  Here I wouldn’t recommend bringing the computer with to log patients as you are seeing them (if you are by yourself, because when I had a question to be on the safe side i would bring anything valuable with me in my bag into the A&E to find the general doctor to get the answer I needed… the computer is just one extra thing to carry for this).  Other highlights of Port Maria were getting to do blood draws, an I&D of an abscess, and start an IV (as here it is the doctors that do these things rather than nursing/ancillary staff). 

Annotto Bay
I also had a great but different experience at Annotto Bay.  Annotto Bay had a lot of damage from Hurricane Sandy– the roof blew off the pediatric ward and many other buildings.  Currently they are working in a makeshift pediatric ward, while they are working to repair what has been damaged.  Currently, they are working on the building that was the A&E department. There are two general doctors that were working there each morning and then Dr. Ramos (a pediatrician) would come to round.  It was wonderful working with all of them.  Rounds were a great way to gain some education and insight into how things are done here in Jamaica.  Dr. Ramos also highlights some differences between medical practice and the culture here in Jamaica and what we see in the Unites States.  This educational aspect was very helpful in understanding the people here and gave me more guidance in the information I should be giving for anticipatory guidance for well visits and for caring for common medical conditions here.  On Wednesdays, I would see a couple of the inpatient cases then would round with Dr Ramos and the team.  Generally, Wednesdays finished in the early afternoon.  On Thursdays, I would arrive and go straight to the clinic.  Here we would see hospital follow up patients, patients with chronic medical conditions that needed follow up, referrals, and well baby visits (for an initial hospital follow up and anticipatory guidance after being born– usually were ~1-3 weeks old and if they were doing well, they would not require any further visits, just routine follow up with the health centers to get their immunizations).  The clinic would be a steady flow and there were plenty of patients to be seen.  One of the doctors that I had worked with the day before in the ward would be there with me seeing patients (again, a great resource when you need to figure out how to do a referral, navigate the healthcare system here).  Dr Ramos would also be there seeing new patients himself.  The day would finish once we saw all of the patients that had been there waiting (typically mid afternoon).  Annotto bay was ~45min-1 hr drive.

Port Antonio
I was actually only here on one Friday (as the first week, I had spent an extra day at Port Maria due to transportation arrangements).  Port Antonio is ~1hr40-2hr drive.  One of the administrators from the hospital drives you both ways.  I spent the morning here doing inpatient (seeing the 11 inpatient patients–bronchospasm, rule out sepsis, 2 social cases/holds, a burn patient, dehydration/GE), then in the afternoon saw ~10 outpatients.  The outpatient area was a little further away from the A&E so it was a little further to go to find someone to help you arrange a referral/further care for a patient.  The benefit was that my husband, who is also a physician, was here with me for the second week and he could run up to find what we needed for someone while I kept getting a history, charting, examining a patient.  Again, Port Antonio had a good patient volume.  Seeing patients in the afternoon there was a slight disadvantage because by the lab was then closed so there was no way to send someone for lab results and then have them wait for the results so I could see them before the end of the day.  There were a couple patients that I sent for labs and then had to just have them make the next available appointment in the clinic to follow up.  It was definitely a busy day there though! The people were very patient even though they had been waiting since the early morning to be seen.

The Resort Highlights:
We did the snorkel trip out to the reef and enjoyed getting to see some fish– not as much quantity wise (we didn’t see schools of the same species), but we saw plenty of colorful different fish.
The food is really good with a great amount of variety.  We enjoyed eating at Eight Rivers, which was probably our favorite.  We spent a lot of time eating at The Patio and had some great pasta and snapper.  The staff is really friendly and the service is great!  Everyone in the restaurants, working at the bars, the entertainment team was very friendly and nice!  I have heard great things about the steel drum band that plays on Wednesday nights, but unfortunately we missed it!  Monday nights is a dinner buffet beach party which was really nice as well!
We spent a lot of our down time enjoying some amazing weather on the beach and swimming.  The weather was a little up and down the first week with some rain, but the rain here usually doesn’t last long.  A lot of times it will rain during, the night or early morning hours, but by the time you are leaving to go get some breakfast– it is all sunshine.
We would fill up the couples resort water bottle with ice water for the day to bring with us and brought little sandwich bags and would pack some pastries, cereal or fruit from the breakfast buffet to snack on for lunch at the clinics.

Some helpful things that I learned:

Asthma/Bronchospasm:  They do have spacers available at private pharmacies but the patients do have to pay for them.  I had not really thought about how nebulizer machines wouldn’t be as readily available.  One of the doctors mentioned that she sometimes tells families to do a makeshift spacer if they can’t afford to buy them by having them put an inhaler into the bottom of a paper/styrofoam  and then hold the open part of the cup up to their mouths.

Eczema/Dry Skin (especially in babies):  In Jamaica many families will put chemicals/potential irritants into the bath water (which I initially didn’t know to ask about).  These things include baking soda, blue (which is like a laundry detergent), etc.  They also will often bathe the baby in cold water and frequently will use wet wipes on the babies faces.  I found this information helpful so that I could tell families to avoid these things.  They do carry emulsifying soaps which are mild and unscented here which is what Dr. Ramos told me to recommend to families.

Neonatal conjunctivitis:  I was interested to find out that the vast majority of pregnant women with vaginal discharge do not get tested/treated with antibiotics.  It seems that because of this there is more concern for chlamydia/gonorrhea due to the fact that so many cases go untreated in the mothers.

Sepsis in infants:  Blood cultures aren’t as readily accessible down here so they rely on the clinical status of the patient for treatment.  Many babies will be admitted for concern for sepsis and then receive a total of 3, 5, or 7 days of antibiotics depending on how they do clinically.

We had a great experience, both at the resort and at the hospitals.  It was a wonderful educational experience, and we hope that we were able to help some of the children in Jamaica!  The people here were all very friendly and the patients and their families were appreciative! 
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It’s my last night in Jamaica
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It is with a definite sense of sadness that I find our stay coming to an end. I regard it as having been a wonderful opportunity to have experienced another culture, practice pediatrics and get a taste of a tropical paradise in an all-inclusive resort.
The time was a nice blend of culture, work and enjoyment. I found it mind expanding not to be so dependent on technological medicine we have come to be relie upon, and to free ourselves from are obsession with the clock. Jamaicans are polite, relaxed and respectful, at least all that I have encountered on this trip. What they lack in material possessions is made up for their joy and laid-back life style.
Thanks are due to the Issa Trust and its president Diana Pollard for arranging this opportunity for me and my wife, Martha, to partake of this most beautiful island’s culture.

Richard
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This is my second week at the Edgehill School for Special Education in Port Maria. I am getting to know these bright eyed students better and learning their names, many are names I’ve never heard before. I taught the song “It’s a Wonderful World” in American Sign Language. One of the teachers found the Louis Armstrong version on the computer and played it along with our singing and signing. That was very effective!  I am leaving my Sign Language book with the school.

Since there are 45 students of various abilities and ages, I modify these lessons accordingly. Paper and pencils are ALWAYS in short supply, and the drawing pads I brought were used up, so I bought more at the local book store.  Dry erase pens are also something which is consumed (dried up) and need replacing. I bought more, but that is also in need as is a copy machine (someday).

Sometimes, I use patterns to trace around. All the art work was displayed in an Art Corner. Most of it I had covered with Saran Wrap, but one day, there was a torrid of rain, some blowing sideways through the windows, and some of the artwork was ruined, but much survived and is still displayed. The students stand in front admiring their artwork and that is a thrill for me!!!

There is an ART CORNER now at the school.

1. tracing their hands with pencils and using watercolors to fill in —taped together to make a big poster

2. used oil pastels (there was a set given but not used, since the teacher didn’t seem to know how to use them—she appreciated learning—I  brought in samples of Hibiscus, fern leaves, Mousetail pods, grape and almond leaves. The students made lovely botanical art which I taped together in a poster.

3. used soft pastels to create still life–I brought in pineapple, papaya, apples, banana, and star fruit for the students to draw and fill in with the pastels. I taught them about how to see and draw the shadows that these fruits cast on paper.  These pictures were mounted and displayed.

4. used old magazines (which the activity director at the resort gave me) and cut out photos of various people doing jobs. These were glued on paper and the students filled in with markers “the rest of the story” This tied in with their Career Day at the school. The speakers who were scheduled didn’t show up, perhaps due to the rain, so I was a speaker. I also taught a game to the whole school which seemed to be a hit. “A…my name is……and I live in ……..and I like……..” It’s a great game to teach thinking skills as well as geography.

5. I will be using watercolors and crayons to teach the concept of symmetry making butterfly pictures.

I think that I’ve enriched the lives of these young students as they have enriched my life, too!!
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On Monday and Tuesday this week, I was working in the clinic in Port Maria and saw two complications of tinea capitus . The first child I saw on Monday was referred in from another clinic for an I&D of a scalp swelling that was not getting better on oral antibiotics. I sent the child to the A&E for the procedure. When I returned Tuesday, I spoke to the Dr. Mighty of the A&E and she told me when they opened up the swelling several live maggots came out. This she said happens when tinea goes untreated and the necrotic tissue is a source for the maggots. They were treating the child with a power that is cidal to the maggots, in addition to Griseofulvin and shampoos. This was a new one for me.
The second case I saw on Tuesday. A child brought in by his aunt, who had custody of him for most of his life. She said he had scalp lesions for several weeks. When she removed the bandana covering his head, I saw large bald spots that were boggy and oozing. It was a kerion, an inflammatory reaction to tinea. In thirty five years of practice in America I could only recall only one or two cases. I was advised to admit him for oral Griseofulvin, Prednisone, and to have the social worker access his home life.

Both these cases gave me a new respect for possible complications of untreated tinea capitus.

Richard
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Our First Week
 
Well, we just finished  the first of our two week volunteer rotation here in Jamaica and it has been interesting,
educational, fun and at times tiring. Really, though, it has turned out much better than we could have hoped.
 
On the medical side, all of the clinics are a little different. Port Maria, where I spent Monday and Tuesday, was the most Spartan in
terms of facilities. Monday started off poorly when I was waiting in the lobby for a ride and after multiple phone call discovered no one knew I was to get picked up.
Dr Ramos interceded and put me in touch with the hospital administrator who then sent a driver. Even though I arrived about an hour and a half late, I was able to see all the
patients and leave at a reasonable hour. I met several of the hospital docs who were all friendly and happy to have me. They asked me to make an educational presentation next week, and I agreed
to give a talk next Monday on asthma, a subject I am quite familiar having championed it from my time at Kaiser -Permanente. I asked them to bring up a case on Tuesday as a spring board for a discussing of fluids and electrolytes.
Wednesday,  I was  in Annotto Bay on their Pediatric Unit. There Dr Ramos spent about three hours in a most didactic fashion reviewing with the residents the cases on the ward. There was a new nephrotic/nephritic,
a child with recurrent seizures and a baby with hypoglycemia among others. He is a great teacher and the process stirred memories of years ago when I was a resident physician. The next day, I was in the outpatient seeing children who had been recently discharged, either as newborns or with some other medical problem. The facilities were an improvement on Port Maria in that I had a real table to put my things and a
chair with wheels to sit in with an adjoining bathroom.
Friday I went to Port Antonio, a two hour drive. I was picked up by the hospital administrator, Patrick Campbell. We had a delightful conversation that spanned such topics and the economy, lifestyle and religion of Jamaica as contrasted to the USA. The time of the drive went by quickly and I was pleased that I did not suffer any car sickness like others had warned me about. In Port Antonio I saw a few children who were referred from local health centers for such conditions as poor growth, recurrent chest pain, etc. I had some free time and went to the A&E( their ER) and saw a few children with minor problems.
 
I will have to admit, staying here at the Couples Resort is a real treat. I am taking piano lessons at home and have been able to access the piano at the resort for some practicing every morning before going to work. When I return from work, on almost every day, I have taken a tennis lesson with the local pro. He is a wonderful teacher and was formerly #2 player in Jamaica. The food is great and there are activities every evening, though we tend to turn in early to be able to get enough rest to be prepared for the next day. Today, Saturday, Martha and I were off together and we went on a guided nature walk of the property and then a snorkeling trip to a local reef. It definitely has made us appreciate the beauty in the natural setting we find ourselves.
 
Now onto week #2 and we will see what new adventures we well encounter.

Richard
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Martha’s Blog:


My first week at the Edgehill School for Special Education, in Port Maria, formerly called the School of Hope, went well. There is a wonderful staff of patient, kind teachers. I have been working with each of the 3 classes (45 students) to teach some sign language, alphabet recognition, and some signs which might be helpful for the less verbal students. Each day, I presented art lessons using the art materials I brought with me from California: tempera paints, watercolors, fingerpaints, soft pastels, and colored marking pens. Since the director of the school told me that there will be an art contest in a few weeks, I’ve mounted some of their finished works for display. Working in with students to complete a project, build creativity and self esteem, has been part of my goal. Luckily, I brought some plastic aprons to protect their uniforms since some of these projects have been a bit messy.  I have taught some art theory, too, using a color wheel and some techniques for using the materials. I have found these wonderful students have been instilled with the admirable qualities of showing respect, taking care of materials, and cleaning up after themselves. Fortunately, Diane arranged for  a wonderful driver for pick ups at the Couples Resort and drop offs at the school . He has also gone with me to help me find additional supplies. The school has some art supplies, but they are in short supply of paper and other school supplies, and have no copy machine.  I’m looking forward to next week at the school.
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I thought we should introduce ourselves as the newest, but oldest in age, ISSA volunteers. My name is Richard Pastcan. I am a semi-retired pediatrician, having worked for Kaiser-Permanente in Northern California for 32 years. For the past three years I have been at a community health clinic serving mostly low income and Spanish speakers as a general pediatrician. So unlike the other volunteers who were in their last year of training,  I represent the other end of the career spectrum. I am anxious to experience a different form of health care in a different culture.
I am fortunate to have my wife here with me to share in this experience. Martha is a retired teacher of the deaf, and the ISSA program director Diana Pollard has connected here to a special ed school in Port Maria. Martha has come with a duffle bag full of art supplies and hopefully this will help to engage the students.
We arrive at the Couples Resort two days ago and it is really as nice as all the prior blogs have described. The setting is a tropical paradise, the food is great and the staff is most helpful. It was good to come a few days early to get used to all of this, and get to know the surroundings a little. Yesterday we went to Dunn’s River Falls which was a really memorable experience walking up a picturesque waterfall. I got to take a tennis lesson in the afternoon and this also made me very happy.
We’ll let you know how are first days work .

Richard and Martha
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“The opportunity of to volunteer with the Issa Trust Foundation in Jamaica was invaluable.
As a physician working in an environment with limited resources, I learned to become more reliant and confident in my clinical skills, and really challenged to order laboratory or r imaging studies which are only absolutely necessary. I developed the utmost respect for the physicians who work in Jamaica, who every day work so hard to treat children without medical equipment we take for granted, such as CT scans, blood tests, blood gasses, cultures, and simple things like growth charts, which now seem like luxuries. Working in a country side by side with natives of
the country is an amazing to learn about a culture and a people. It is fascinating to learn about the healthcare system and the medical training system in another country. This organization is unique in that volunteers are provided with 5-star accommodations at an all inclusive resort, and volunteers have full access to all of the activities at the resort, including scuba diving, horseback riding, water skiing, amazing meals. It is an amazing opportunity from which all pediatricians would benefit.”
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In follow up per Dr. Stephanie’s blog, Dr. Ramos in Jamaica shares the following information:

Our recommend treatment for Ophthalmia Neonatorum or Neonatal Conjuctivitis does not differ from what is recommended and practiced elsewhere including many Pediatric hospitals
in North America.

Providing that the suspected etiology is infectious, then “triple antibiotic therapy” is
recommended. This consists of:

Topical: Tetracycline
Eye Ointment 1% for 7 days
Oral: Erythromycin,
50mg/kg/day (divided q 6-8 h) for 2-3 weeks.
Paraenteral: Ceftriaxone
50m/kg/ single dose (maximum dose 125mg).

Neonates treated as outpatients should be reviewed within 2 weeks.

Based on my experience (over 10 years) using this “triple antibiotic therapy”, the vast majority of cases (>95%) will resolve.

We do not routinely recommend admission, unless there is an indication for it,
example:

– Signs of systemic involvement (hyper, hypo or unstable body temperature, vomiting, coughing, sick looking baby, etc)
– Severe ocular signs (risk for intraocular complications)
– Concerns about treatment compliance or proper follow up.

If the baby is suspected to have a systemic sepsis in addition to the above outlined treatment regimen, we recommend a combination of Penicillin/ Aminoglycoside for at least 7 days or
until cultures reports are available.

It is to be remembered that cohorts differs from country to country, even from state to
state; therefore we must be aware of this when we approach a population of a different background than the one we are used to attend. Causative agents prevalences, popular practices, and socio-economic status all might also influence the way we approach these conditions.
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