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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.
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This is my third time here, and it went as smoothly as always. Arrival in the airport is much like many other international airports. About 30 minutes before landing, we each received a Customs Declaration form to fill out. Having a pen on the airplane saves you from having to ask around.

The process afterwards was rather straight forward. Deboarding, getting your passport checked, picking up luggage from the carousel, then going through customs all took about 10 minutes combined. I was lucky having arrived when the airport was empty (7:30PM on a Tuesday evening), and I’ve heard that the process took about three hours for Stacy McConkey who arrived only a few days earlier.

I lounged around in the Couple Resort Airport Lounge which was on my left as I walked out of the Customs area. I happened to be the only one there. I told the cheerful man at the desk that I was going to Tower Isle resort, he tagged my luggage, and offered me a Red Stripe. I waited for about 20 minutes and then my bus was off. It was an hour’s ride to the resort.

Checking-in is much like checking into any other hotel, except you are greeted by a “welcoming committee” with cold drinks and a cold wet towel. I took my key to Villa 9 and was escorted to my room. I met up with Stacy McConkey and Diane Pollard in our villa. I knew the mission was off to a good start when I saw our accommodations – two-bedrooms, each with its own bathroom, and a large living room and an attached kitchen and dining area. Three 32-inch flat screen TVs, a fridge, and free wireless internet access made our home away from home much more comfortable than I expected. I’m told a microwave will be made available, but I’m not sure if one is necessary since food is offered at the resort pretty much 24-hours a day.

We are even given an option for having breakfast delivered to our room. This will be a welcome option when we are scheduled to leave the resort earlier in the morning than the 7:30AM buffet opening. And this is a rather strict time. Most everything in Jamaica runs on “Jamiaca time” where things are often, and unapologetically, delayed 30 minutes or more. But when it comes to breakfast, 7:30AM is strict and not a minute before. It’s fun seeing the breakfast servers grumble at guests who try to hit the buffet a few minutes earlier.

Sleeping after the long day of travel will be easy. Tomorrow we leave to Port Maria at 8AM.
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