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The steady whirring of the overhead AC unit at Port Maria is almost hypnotic after the steadily rising cacophony of the morning breakfast buffet at the resort.  Several wedding parties arrived over the weekend, injecting both youthfulness and a certain amount of noise to the system.  While this is good for resort business, I can’t help but be slightly wistful for a beach lined with friendly open lounge chairs, their white cushions warmed by the sunlight, and devoid of the oppressive smoke from a cigarette, or the spicy smoke from other inhaled ignitions.


The pre-crowd beach life

Laughing at my own sense of entitlement, as well as the knowledge that the bustle will slow again in a few days, makes it all right. Flashback:  The ebb and flow of patients continued throughout the week.  Dr. Ravi, who is the more or less the equivalent of a chief resident, was very patient and helpful navigating the system.  We had some excellent discussions regarding differences in admission criteria in and among hospitals in the US, Jamaica, and around the globe, as well as the finer points of “whose patient is this?”


Starting the week at Port Maria A&E (accident and emergency).

In Jamaica, Good Friday and Easter Monday are both public holidays.  The energetic pomp of the marching band was a welcome addition to lunch on Monday. IMAG0894a

Yay band!

As such, it was a welcome slow vacation weekend, despite my need to relearn the skill of relaxation, which I hadn’t necessarily lost, but had partially buried under a few layers of dirty scrubs, floor tiling equipment, and board study DVDs.


“Oh, THERE you are, Peter!” (Peter : relaxation)

In rediscovering relaxation, I took advantage of the free scuba lesion here to take my first ever dive.  While the bulk of my attention was focused on diving techniques of “breathing”, “kicking”, and perhaps most importantly, practicing “not touching anything,”  there was enough of my sensorium available to marvel at the towering coral wall to one side and the majesty of the vast blueness to the other.  We explored the shallow shelf of the wall at 40 feet deep.  For those that are absent diving experience, it felt like being hit with a shrink ray and thrown into a tropical aquarium in the role of the plastic diver figurine.  Had we been at the site of the sunken ship (an old WWII ship that the Jamaican government elected to sink off of the north coast for scuba diving tourist purposes), the sensation would have been complete.   The coral caves were marvelous and filled with bright oranges, blues, and purples.  The neon yellow shock of a trumpet fish, the ponderous waggle of the horned, cow-like trunk fish, and the sneaky, sandy camouflage of a puffer fish all made appearances before our steady ascent back into the light world of air. Otherwise, the weekend passed with fine food, good friends, plenty of sun, exercise, and only a little bit of time reserved to read and study.


Sunset from the deck of the Bayside Restaurant.

I had a small visitor to the villa (below).  I was suspicious that he was merely freeloading and not volunteering medical services for the foundation, but as I haven’t seen him since, I haven’t been able to confront him. IMAG0886_1

The freeloader.

Yesterday, I had the unique experience of diagnosing sickle cell disease (correctly!) for the first time since medical school.  The rate in Utah is low owing to a relatively homogenous population to the point that most sickle cell patients become case presentations for our residents. Unwarranted self-congratulatory pride aside, the experience of obtaining the diagnostic test and subsequently establishing appropriate follow up was simple and efficient.  It is this aspect of Jamaican care that I hope others can see.  While the resources are limited, they are largely put to good and effective use by those who see to their management. Present time:  Sticky humidity hangs in the air this morning across the island in the pediatric unit of Annotto Bay as I type and wait for morning rounds to commence.  One of the pediatric surgical patients who last week had his legs tied up above his head has since been cut loose and sits patiently in his crib.  Until rounds start, it seems like good fun to make faces at each other.  And it is.
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Bright, cheerful puffs of sound are the polytonal point and counterpoint of the morning traffic conversation on the way to the hospital.   The tempo is at first a pleasant andante as we pull out of the resort with an occasional “hello” or “coming along side” through the country.  Today, columns of spicy, sweet, hazy smoke rise through the clear morning air at irregular intervals along the road and sometimes back into the hills, a sign that the rubbish collection system is currently down.  As we drive closer to town, the conversation accelerates to a brisk allegretto as the roads become filled with cars, and with bicycles and pedestrians on their way to school or work who ride or step into the street without thought or hesitation, and with goats, which carefully look both ways before venturing into the busy morning traffic.  Owners of the many tiki shops and restaurants are starting to arrange their wares for the day into neat stacks of colorful fruits, or strings of smoked fish, or cloth bags, or t-shirts.  A police car tends to a small altercation between a guilty-looking gray sports car with a large rear spoiler and an unassuming bicycle just before the turn-off to the hospital, which I’m just starting to recognize and expect. Sitting in the office waiting for the morning’s dockets, the other emergency medicine doctors and the chief medical officer pop their heads in to make sure I’m comfortable. (I am).  One brings me up to the pediatric ward to say hello to the few patients up there, one of whom is a toddler who was hospitalized for treatment of a severe skin infection.  She looks quite well, with small dark eyes peering curiously at me underneath the sky blue gauze of the surgical hair net she wears, and I am told that she is well, but being kept for evaluation of neglect.  Her brother, it turns out, was recently hospitalized for a similar infection and his mother received copious education at that time.  Fortunately, his sister is better off as, unlike her brother, she did not have “little people” (maggots) in her infection when she was brought for treatment.  Nonetheless, there is understandable concern regarding the household hygiene.  Her case led to an informative discussion of the local social work system, which is not substantially different from home, though they may be working with even less funding and support. The day was a rush of orthopedic evaluations and skin infections.  By the time I rode back to the resort, the smog from the morning’s rubbish fires had been replaced by majestic afternoon storm clouds billowing above the mountains.  Not a bad way to end the work day.
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Work day 5:  An unexpected delay in transportation this morning allowed for a very welcome extra cup of coffee with some new friends prior to their departure from the resort, and perhaps I am slightly more awake than usual going in to the work day as a result.  Regardless, I don’t promise improved coherent thought. Flashback:  Time here manages to creep along slowly, but then disappears without warning and it is abruptly the start of the second work week here in Jamaica.   Partially, I attribute this to the consultant nature of the position here, which is distinct from our role as primary care providers in the US, and means that business ranges at random from scattered showers to a monsoon-like deluge (Side note: I am told that ‘monsoons’ don’t really happen in this part of the world.  It’s just a colloquialism we apply to ‘heavy rains’).  Last week was no exception with a slight trickle of patients most days, with intermittent 2-3 hour rushes of dockets piling up on my desk. Present Day: I will now take a brief pause in typing for just such a deluge. [Cue elevator music].  Seven rapid-fire patients and some furious chart scribbling later, I’m back.  Everyone has been quite patient with me learning their system, and responsive when I ask how things are done here, or what medications are available for use in a given situation, or for a helping hand when drawing blood. Thus far, the clinics here are very livable. They are well tended, clean, and organized.  For reference, here is my office space in Port Maria:


As compared to other places I’ve worked and visited, I find myself wondering how recent the organizational changes are and if it has anything to do with the local doctors.  Perhaps it is just population bias, but there are many people here who have completed training at institutions in Europe and North America, but then return to Jamaica to share their skills and knowledge.  This is in contrast to other areas of the world, where expatriation of trained doctors is a major issue.  I don’t know what that means for Jamaica in the next 20 or 30 years, but I hope the trend continues such that it obviates the need for volunteers beyond guest speakers for educational purposes. Treatment-wise, I’m seeing a lot of asthma, otitis, skin infections, and gastroenteritis and enjoying the practice in expanding my differential and stretching my brain.  One poor little guy got on the wrong side of an ant hill earlier in the week (the side with the ants on it), and had bites up and down his leg and his groin that were itchy and had become secondarily infected.  He shook his head solemnly in agreement when I noted that the ants had not been very good playmates.  Only one child needed to be admitted for observation after an incarcerated, necrotic (rotting) accessory (extra pinkie) finger was removed, which was interesting, but not too interesting.  Not being too interesting as a patient is a good goal, as it suggests a reasonably good prognosis.

Island activities:  As the medical portion of this post was a good bit longer than intended, I’ll keep the extracurriculars short.  Saturday morning’s activity was a hike up Dunn River Falls, where I was adopted by a family from Pennsylvania, and held hands with them for the duration of the hike.  Ordinarily, the holding of hands while hiking up or downhill on wet rocks is not the recommended method, however, “no worries, mon.”  Another couple saw me sitting down to dinner that night and enthusiastically rushed over to insist that I sit with them as “Dr. Jess shouldn’t eat alone!” and introduced me to their vacation group, including a fascinating couple from Bosnia.  Sunday morning was a glass bottom boat tour, which wouldn’t have been complete without the very talkative gentleman from Ohio who described his and his brother’s multiple marriages and educated me on the finer points of travel throughout Mexico, Jamaica, and the Dominican Republic at some length.  Unfortunately, the roar of the engine became too loud and all I could do was enjoy the scenery.


Overcast day at sea


The guide said NOT to climb these honeycomb rocks.  Which look quite climbable.


Dinosaur rocks.

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Before I get started, a heartfelt apology to my writer friends.  You would be able to convey this experience with much more elegance, and quite probably with more grammatical expertise than I am capable of producing. Work Day 2:  The day really began en route to the hospital.  Imagine driving along a winding road through the Caribbean forest with the shade of the banana and almond trees cooling the humid air to a pleasant morning breeze.  A feeling of familiarity pulls at the fuzzy edges of your still awakening consciousness and you realize that the hokey pokey has insidiously emerged under the cover of a steady reggae beat coming through the car stereo with an overlay of laser sound effects.  Go figure.  The standard small-country driving experience, where the primary and possibly the only rule is, “Do your best not to hit anything, but if you do, oh well,” is not sufficient to wake me up, but reggae laser “Hokey Pokey,” gets my attention.  Now being slightly more awake, I see a few hints of the community I’ll be working with over the next month:  the children walk together dressed in neatly pressed school uniforms, every car full of people, and those that aren’t pulling over to pick up one of the people dotting the shoulder of the road, neighbors calling out and waving to each other on the way to work.  Here at the hospital, everyone helps keep an eye on one of the clinical officer’s children, Shaun, who has come in for the day.  He’s about 3 years old and is happily thumping away on a succession of musical instruments.  First, with rulers repurposed as drumsticks, then with a truck and a table, and now with a reptilian themed Fisher-Price ™ alligator xylophone and an allosaurus figurine. Flashback: After arriving this weekend, I spent the first day sleeping and relaxing at the resort, which was a welcome recovery period after a week of night shifts back home.  I thoroughly enjoyed Monday night performances by a magician, limbo king, and fire breather.  On two occasions, I was a volunteer on stage:  once to assist in the magical appearance of a dove (I still have no idea where it came from!), and once to hold a lighter for the fire breather.  Interestingly, the other two assistants for the fire-breathing performance had 2-foot long torches, which they held extended at arm’s length while the fire breather sputtered kerosene over the flaming end to create a small fireball over the audience.  He performed the same trick with the lighter in my hand.  This was not one of the nice, long, extended lighters, but a standard 3 inch cigarette lighter.  As a result, both the kerosene and the resulting flame were much closer to my person than to the other two volunteers.  Later, I wondered if their hands and arms smelled as much of kerosene as mine did, or if they avoided most of the spray by virtue of lengthier props.  I will likely never know.  The resort is lovely, though I suspect it will be difficult to keep my girlish figure intact given the highly accessible supply of quality food and drink.  Spinning instructor, Mike, may be able to help me stave off the sloth. Thus far, there’s not a lot to report on the medical front.  The clinics provide a dose of reality in contrast to the grounded cruise ship feeling of the resort.  Yesterday afternoon, I saw a few patients at Port Maria, where they’ve recently acquired a wall unit ophthalmoscope and otoscope.  In general, the clinics are well-appointed and the other doctors and staff have been welcoming and supportive.  It’s always a bit of a gear shift to go from “pull out all the stops” medicine in the US to “practical medicine” elsewhere with a sense that my brain is finally coming out of hibernation and that I am indeed capable of setting up my own clinic space, and doing phlebotomy, and reading plain films and all number of useful things which have been lost in the hierarchy back home. Present Day: We rounded this morning with Drs. Ramos and Fisher, who are as thoughtful and enthusiastic as others have described and I look forward to learning from them over the next several weeks.  This afternoon will be my first round in the A&E unit seeing acute patients, which is roughly equivalent to our emergency room (or ‘department’ if a ‘room’ just wasn’t enough).  Wish me luck!
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