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Having reached home (brrrr, it’s cold), I thought I would summarize the last week as well as give a few thoughts about the last month. My last few days flew by — the 25 wk preemie was holding his own on CPAP, I admitted a child with failure to thrive (less than the third percentile for weight/height/head circumference), went to Ocho Rios for coffee (yum, Jamaican coffee…) and a movie, and wrote a few more referrals to Bustamente. Saturday I soaked up as much sunshine as I could while saying ‘good-byes’. Despite my best effort, I am still ‘white with spots’ (freckles) as one of the children at Annotto Bay described me :)! My return flight was smooth including customs, and I discovered that it is indeed 20 degrees in Iowa as well as Jamaica…unfortunately, one is Fahrenheit and one is Celcius.

It is incredibly hard to believe that the month is over. At the beginning, I was slightly skeptical about what this experience would be like. I have no more doubts now! For those looking into trying this rotation, I definitely recommend it. It is a great chance to ‘try your wings’ before entering fellowship or taking a real-world job, since you get to function a lot by yourself. Also, the rotation exposes you to a few things that you don’t see often here (at least I haven’t — such as lots of versions of fungal infections, worms, rheumatic fever).

Helpful hints: Take something to read or study with you every day…you never know when your driver will stop at the airport, another clinic, or any number of places on the way. Not to mention that during the majority of my stay, I rode with other hospital employees rather than the drivers as the hospital vehicles were often in the shop. Therefore, you may be waiting for he/she to finish work. On the bright side, you can obtain many different perspectives of Jamaican healthcare by talking to the numerous people who provide rides — I learned a lot from the hospital administrator, parish manager, parish accountant, health officer, and a taxi driver in addition to the regular drivers.
Along the same lines, always take something to eat / drink.
Play volleyball at the resort — apparently, I am the 3rd of 3 of us to do so…it would be fun to continue this tradition :).

Most helpful items I brought with me daily: Otoscope/opthalmoscope & tips…could have used curettes. Harriet Lane, hand sanitizer, stethoscope, toilet paper. Needs I encountered: Port Maria clinic could use some Pap Smear swabs, Annotto Bay would love a Red Book…and I don’t know for sure about Port Antonio.

Enjoy! Feel free to email regarding any questions you have. Thanks for following my journey!
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For those of you who have read previous blogs and remember the triplets…here are two of them who came to clinic last week. As you can see, they are doing very well! If anyone would like to contribute to their care (diapers, etc.), please let Diane know — I have contact information for their mother. I am assured any help would be greatly appreciated!

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Pictures from the last week:
Right: This infant’s umbilical cord was treated traditionally, with a powder concoction. I encouraged his mother to utilize only clean water from then on.

Left: This infant has string on his forehead to prevent hiccups (I learned it does not have to be yellow string…but his mother said this one was working well!)
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My last day at Port Maria is now finished…with a bang. As with most mornings, I sat on the wall of the little circle by the pathway leading to my villa until my driver arrived. As often is the case, I called around 8:10-8:15 to make sure someone is coming. We arrived shortly before 9 AM at Port Maria and I set out my supplies. I asked for more prescription paper and filled out a few in advance as Tuesdays tend to be busy. Patients began to trickle in, mostly referred from the nurse shortly thereafter then came in a flood by 11 AM — 37 of them! The number would have been 40, but 2 turned out to be adults and one disappeared before I got to her.

Once again, most of the dx for the day were tinea or URI. I also saw preauricular ear pits/neck pits in an infant — she is to see ENT in Bustamente, consider renal U/s as well. I also saw a few more such unusual cases. I had brought an apple, but never found time to eat it — I feel so sorry for those waiting. I finished up around 4 PM at which time my driver came to find me (usually I walk around the back to the administrative office to have someone arrange for a ride). Luckily, I had time (while I waited for him to drive to the gas station and return) for a few last photographs of the helpful office staff / nursing assistants and to say my good-byes to Dr. San San Win and a few other administrative staff. While this has definitely been my busiest site, I also felt very productive and helpful here!
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This past weekend was amazing as my fiance flew in and we were able to enjoy many of the resort perks as well as some time together. Amongst many other activities, we climbed the waterfall at Dunn’s River Falls, took a trip on the glass bottom boat, and talked to the man selling shells. We also ate dinner at Eight Rivers/Bayside, both of which were excellent. I even managed to eat my entire meal at Bayside with chopsticks!

My Monday morning had a somewhat rocky start as the driver did not arrive until 9 AM. Then I received a phone call while at work that the resort thought I was leaving today and was looking for me. Oops, apparently my fiance’s departure date had accidentally been recorded as mine as well! That was quickly fixed and the remainder of my day at Port Maria ran smoothly. Themes for the day were tinea, URI, and gastroenteritis although I also consulted on two inpatients; one with seizures and hypotonia in great need of a Pediatric Neurologist and the other with marked lymphadenitis.

Things I learned today or along the way:
Jamaican ambulances are staffed by a driver, a nurse, and a porter. They have nebulizer machines, oxygen, and scissors amongst other things on board. The few available ambulances remain busy transporting patients from home to the hospital in addition to hospital-to-hospital transfers for tests including x-rays!
Few families have paracetamol (tylenol) at home.
When an x-ray is ordered outpatient, it is generally given to the patient. This means a patient sometimes appears in clinic with xray or labwork in hand. Dockets (charts) are kept intra-facility while the patient may go to many facilities, so you may not have the reason behind the testing available.
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Mid-week already, time seems to be moving at a steady clip. After Sunday’s adventures in beach volleyball, I confess I was a bit sore on Monday. Nevertheless, I saw approx 25 patients at Port Maria. I’ve noticed a trend toward multiple diagnoses as everyone comes in with one chief complaint but then asks me to look at a skin infection or discuss a cough. No cases of Ackee poisoning for me as of yet, thank goodness.

Tuesday is Children’s Health Day at Port Maria, which always signifies a busy clinic for me, especially after around 11 AM when most of the well-children have been seen for vaccinations. Several of my patients were referred from the nurse practitioner, generally for URI symptoms. I was thrilled to find that a patient from last week returned with completed lab work!

Today, I returned to Annotto Bay Hospital where the three young doctors were already hard at work seeing the 13 inpatients. The 25 week infant (I still suspect his gestational age to be closer to 28 wk) continues to do well and is now on room air. Sadly, the child we placed on CPAP last week died.

I greatly enjoy my trips to Annotto Bay and rounding with the team. Today, we discussed cases of likely and proven rheumatic heart disease — a rare diagnosis at home. I also continue to marvel at how well staff handle the daily frustrations that come with working in a third world environment. Today, one of the younger doctors and I went to draw a blood culture from a child with likely meningitis (bulging fontanelle, fever) only to discover that there were no more blood culture bottles on the ward.

Tomorrow I shall return to ABH for clinic, then Port Antonio on Friday. I was asked by one of the younger doctors in Port Antonio to discuss fluid management based on their recent GE outbreak. Here, the mild-moderate-severe clinical appearance apply more readily than my textbook examples; I/Os are not generally monitored unless expressly written in the docket (chart), which is only done for the most ill patients and lab work, including electrolytes, may not return for several hours or until the following day.

In addition to Port Antonio on Friday, my fiance is scheduled to fly in on Friday for a weekend stay! I am very excited to try a few more of the resort activities and introduce him to some of the staff members. More adventures to come, I am sure….
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Above: child with vargus leg deformity. He wasn’t particularly thrilled about having his picture taken until after (when he was excited to see himself on the screen), but I think you can still note the change, particularly in his right leg. Taken with permission from the child’s mother.

Next: Mango tree (and Donovan, the guide for the nature tour I went on yesterday). The lush foliage here never fails to amaze me. I’ve seen banana trees, coconut, guava, mango, sugarcane, and many other plants that previously were known to me only by the grocery store selection!
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The weather has been a little more chilly today with intermittent sprinkles — much like the rest of the week. Nevertheless, the planning for tonight’s party at the resort goes on. It is the 33rd Anniversary of the resort which means a lot of activity going on!

The rest of the week has also been full of activity for me. On Tuesday, I returned to Port Maria and saw 35 patients! My hand was cramping from writing prescriptions for clotrimazole cream and paracetamol. Wednesday I returned to Annotto Bay to find that the 25 weeker is still there and doing relatively well. I was very excited to see him. The team and I rounded on the other patients relatively quickly, then I tried to assist the team in carrying out the day’s plan. We obtained a urine culture (unlike at home where we use catheters, they do suprapubic taps here), a lumbar puncture (not successful, but in-process the child developed explosive diarrhea and provided a reason for his fever), and drew blood from several patients.

Thursday was also spent at Annotto Bay; this time in clinic. I took my time (unfortunately for the other doctor who saw 40!). I saw a few interesting cases, including a 3 week old infant who had lost weight since birth. Upon obtaining further history, I discovered his mother had stopped breast-feeding when he was ~10 days old, at which time he developed ‘cold in his chest’. She then tried formula for one day and decided it gave him constipation, and had been giving him nothing but bush tea (a local remedy) for at least a week. She resumed breast-feeding several days before the appointment, but had not been expressing much milk. Apparently cases such as these are not uncommon.

Friday was my first trip to Port Antonio. The drive was gorgeous. I only had 3 patients (this is a relatively new clinic and Dr. Ramos usually sees peds patients here on Tuesdays). All three of them were referrals, two of which I referred on to Bustamente Children’s Hospital. Of the referrals, one child had leukocoria and the other had severe vargus leg deformity. I then rounded on the inpatients where the theme of the day was vomiting/diarrhea.

Other interesting tidbits of the week: The Jamaican workday is approximately 6 hours, although the resort workers seem to double that. “Lasco” is what many children call a powdered milk they drink; however as Lasco is a large company, the term may refer to many other things. June plums are a fruit many Jamaicans eat — with or without salt / pepper. Oh, and apparently housekeeping does not have a key to the bedroom of our villa…so if you want your sheets changed / new towel, either be present or leave the bedroom door unlocked (oops!). 🙂 I think that is enough for now. I shall try to post pictures tonight or tomorrow.
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Back to Port Maria today; I saw 26 patients. Lesson of the day: the Ackee fruit is the Jamaican national fruit. When prepared properly, the inner part is has high nutritional value. When not allowed to ripen or not boiled, the fruit can produce vomiting, seizures, hypoglycemia, and death due to alkaloid toxins. Apparently there has been an outbreak of this recently in Jamaica including several deaths. I will know to ask about this possibility of my patients tomorrow! Pictured above: my clinic room today and a cute Jamaican girl who was my first patient of the day. (Picture taken with written permission from her mother.)
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Day 5, finally figured out the blog — I apologize in advance for the long copy/pasted version of my first week : ) .

I landed in Jamaica on Monday without problem. I actually slept through both flights – the beauty of leaving almost post-call. Customs was easy, and despite a brief oops at airport lounge when my name wasn’t on their list of guests, check-in went smoothly and I am now installed in villa #9 for the next month. In addition, I was able to recognize a vacationing couple who Diane knows and thoughtfully emailed me regarding and I ate dinner at the buffet (yummy) with them. Afterward, they showed me the parrots (really) and the view from their room – gorgeous, I would love to have the pictures they took off their balcony! I spoke with my driver, found the laptop/cell phones, and enjoyed some free time.

Wednesday was my first day on the job. I met my driver in the circle out front and we set off on the winding roads to Port Maria. Arriving at the complex, I discovered ‘my’ room had been damaged by recent rains, so I was taken to the clinic (first building encountered). I unloaded my two bags worth of necessities in a small room; my first 16 patients arrived shortly thereafter. Things I learned today: 1) Dramamine is a good idea, but it doesn’t take away driving down the ‘wrong’ side of the road and the random passing of Jamaican driving! 2) Clindamycin is not stocked at the Port Maria pharmacy. 2) Obtaining a urinalysis by dipstick here means you test pH, sugar, and protein. Diagnoses included abrasion, cellulitis, cellulitis, URI, dental abscess, URI, and my case for the day: a 7 mo with vesicles on her tongue, lip, and under her eye. I wish I had taken a picture and hope she continues to drink well to stay hydrated.

On Thursday, I returned to Port Maria. I was much more comfortable with my surroundings, but much to my chagrin, the first pediatric patient didn’t show up until 11 AM. However, based on the number of mothers who were there and took down my clinic dates for the month, I should have more than plenty from now on! Diagnoses today included: fungal infection, fungal infection, URI, URI, impetigo, and a child with tight heel cords who can’t walk yet/stands on his toes whom I sent to ortho for a referral. I learned today 1) A referral consists of a form that is filled out that the patient then takes to the specialist. I also obtained sheets for x-rays and labs for future use.

Today I headed for Annotto Bay Hospital. Despite it not being c-section day, it was newborn day and we received three admissions in a row. One was a 25 weeker; without a ventilator, incubator, and NVN, his chances will be limited. He will be in my thoughts this weekend. I did experience first-hand CPAP here while helping to combine tubing, a bottle of water, and an oxygen tank.

After three days full of eye-opening experiences, I’m very grateful for the tools I have at my disposal in Iowa. I’m also looking forward to a weekend off — sunshine, here I come!

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