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Yesterday, I worked at Port Maria’s Accident and Emergency Department.  The morning was quiet, the calm before the storm.  I didn’t have a single patient in the morning.  In the course of three hours during the afternoon, I admitted two patients and had to transfer one patient directly to Bastamante Hospital (three hours away) for emergent surgery. 

My first patient to be admitted was a 5 wk old baby boy who came in with fever and cough (likely with a cold).  However, because of his age and his immune system is not strong (and thus he is at risk for a serious bacterial infection), we had to admit him for IV antibiotics and check his blood and urine for infection. I obtained the labwork without problem, but the urine was another story.  In
Jamaica, it is routine to obtain urine specimens from children via suprapubic aspiration as opposed
to catheterization.  While it is the gold standard to obtain urine specimens this way, it is not routinely done in America.  Instead, we do urine catheterizations.  It was fascinating to see how this was done, and it seems surprisingly simple.  All you need is betadine, sterile needle and gloves, and a syringe.  You insert the needle directly into the bladder and draw back on the syringe to get the urine. 


The second patient I admitted was a very active 7 month old boy who had wriggled off his bed while
his mom was trying to change his diaper, and fell three feet onto a hard tiled floor.  He cried immediately, and was otherwise acting normally.  His exam was completely normal for his age except for a large bruise over his left forehead.  I admitted him for observation overnight.

The last patient was a 7 month old girl.  The moment the mom brought her in to the exam room, I knew something was wrong.  She was crying and whining nonstop, and nothing mom was doing was
helping.  Mom told me that she had started throwing up yesterday, and had become increasingly more
fussy overnight.  Yesterday, mom noticed that she had bright red blood in her diaper, and this
morning she noticed scarlet mucousy poop.  Her exam was notable for an increased heart rate, extreme tenderness over her entire belly, and guarding (trying to push my hands away).  Her diaper was filled with poop that looked like currant jelly.  I had never seen that before, but that sign is
pathognomonic for intussussception (the telescoping of one part of your bowel into another that can
cause death of the bowel if not repaired quickly). 



I spoke with the supervising ED doctor, who had never seen intussussception before. One of the
nurses had, and she confirmed that this was consistent with intussussception.  We called over
to Bastamante Bay Hospital, put in an IV and started IV fluids, and transferred her immediately
to the pediatric surgery service there (as there was none available at Port Maria).  Unfortunately,
Bastamante Bay is over 3 hrs from Port Maria Hospital, and is located in Kingston.


My day yesterday was very interesting, if not slightly terrifying.  I am so grateful for the help
that the ED doctor and the nurses here gave me as I was trying to take care of my patients without
knowing the system well or where things were. They patiently helped me out without making me feel
bad for not knowing.  I really appreciated that they did so, but I am not surprised.  Jamaican
people are amazingly warm, welcoming, and hospitable.  

Looking forward to what today will bring. 

with her, not only for her winning personality but because the exchange of ideas was excellent.  Since
we were from different parts of the country, we had our own ways of giving anticipatory guidance, or
managing certain illnesses.  We learned as much from each other as we have from the physicians in
Jamaica.  We also had a ton of fun together. 

This past Monday and Tuesday, I was at Port Maria Hospital, and I worked at their pediatric health care clinic.  Monday was a normal sick clinic, while Tuesday was a shot clinic.  Both days I saw 17 patients by 1:30 pm (approximately 4 patients/hr).  So, to recap, it was busy.  Some cases still stand out though. 

One patient, an 11 year old girl in middle school, came in complaining of pain behind her ankles
bilaterally and wrapping around the front lateral aspect of her foot.  She was an active soccer
player, who had been having this pain intermittently for the past two months (especially
when exercising a lot).  She also had some swelling around the lateral sides of her two feet, and
stated that her dad also had “bony bumps” like hers.  She had already had X rays of her feet, and
those were completely negative for any fracture, or tumor.  Her exam showed that she had tenderness
over the achilles tendon bilaterally and also over the point of insertion of the tendon into the bone
(lateral aspect of feet).  I diagnosed her with achilles tendonitis and accessory navicular bones. 
Treatment for this problem would include rest (minimize activity like soccer and walking) and
NSAIDs (ibuprofen).  However, when I told the mom this, she looked at me with dismay.  “She walks 2 miles to and from school everyday.  There’s no way she can do that.”  

I was reminded anew on how different Jamaica is from America.  Here in Jamaica, all children wear
uniforms to school, and those uniforms must be pressed & cleaned daily.  There is no such thing as
a bus system to take children to and from school, and I frequently see children walking on the side
of the road to school.  Some children even take taxis every day so that they can reach school. 
School here, while paid for by the government, is still a privilege. 

The other surprising patient that I had was an 18 mth old girl with chickenpox.  I had never seen
chickenpox before, and this rash was classic “dewdrops on a rose petal”.  In Jamaica, the goverment provides vaccines for free, but not all vaccines are covered.  All vaccines that are available in the U.S. are available in Jamaica, but families must go to private pediatricians to obtain shots that are not covered by the government. The vaccines that are not covered include vaccines against Hepatitis A, Varicella (chickenpox), Meningococcus (can cause pneumonia and meningitis), Pneumococcus (can cause pneumonia and meningitis), and Human papilloma virus (causes genital warts and anal/cervical cancer). 

Thursday, I met a wonderful 4 year old girl whose mom was worried because she was making a “chuffing” or throat clearing sound everyday, multiple times a day, for the past several weeks. Upon further history taking, I also found out that sometimes she would wring her mouth, or she would blink a lot. Each of these behaviors would last just a couple of seconds, and she would be completely aware throughout. She had done these behaviors for the past year. The little girl was otherwise completely normal. I diagnosed this girl with a tic disorder (? early Tourettes), and broke the news to mom that this disorder can unfortunately get worse (she can develop new tics), and that this might not be curable and medicine would not help. Mom was happy to have an answer, but unhappy that there wasn’t much more we could do. Frequently, children who suffer from tic disorders can be taught behavioral techniques to help minimize how frequently they have tics. I don’t know those techniques, and those that would (speech therapists) were not available. Here, speech therapists, along with psychiatrists and physical therapists are concentrated in bigger cities (like Kingston), with
a few scattered throughout the countryside. 

The more I learn about the Jamaican healthcare system, the more impressed I am at the doctors
here.  They truly rely on their clinical judgement, and are trained to be general practioners who can
take care of people from birth to death.  Many of them can also do surgeries like c-sections and
tubal ligations.  I like to think that during my time here, I have learned to be more decisive and
trust my clinical judgement from their example.

I can’t tell you how wonderful Jamaica has been so far!

I flew in on last Thursday, and started working this Monday on 4/14/13.  On Monday, Kasey and I shared a combined examination room at the Accident and Emergency Department at Port Maria Hospital.  We treated a ton of rashes that day (heat rash, papular urticaria, and tinea capitus).  I learned that when infants are taking Irish, they are actually eating mashed potatoes, and that “he du du” means pooping.   Good times.

Tuesday and Wednesday we enjoyed a wonderful drive to Annotto Bay (approximately 1 hr away from the hotel).   The coconut plantations were awesome, and the bay is breathtaking.  Outside the Annotto Bay Hospital, kids played soccer while a view of the Atlantic ocean stretched behind them.

Wednesday, we started off in the inpatient ward.  There were nine kids to round on.  The scariest part was that our sickest patient was a 4 yo male with sickle cell disease who had initially presented in vasoocclusive pain crisis in his back and abdomen, and subsequently developed acute chest syndrome.  In America, we would have this patient in the ICU and would probably be doing an exchange transfusion. Instead, the excellent nurses and doctors (guided by Dr. Ramos) were managing a very sick child on the ward, and doing a remarkable job with his pain control and fluid management.  I didn’t know that in Jamaica there are only two pediatric ICU units, one in Kingston and one at University Hospitals.  Most patients in their ICUs are on ventilators.  Luckily, our patient was maintaining his oxygen level on 4L via mask, and his pain was under good control with Morphine IV prn. 

Here I am, ready for sit down rounds with Dr. Ramos:   

In the afternoon, we headed over to the Accident & Emergency Department. I had the most interesting case, and 11 yo male who presented with R knee pain after a football (soccer) injury.  He was playing in his first game of soccer, jumped up to kick a ball, landed on his right leg, and another player collided with the front of his lower thigh.  He immediately felt pain, and was unable to bear weight or fully extend/flex his lower leg.  His exam was notable for swelling & tenderness around the lateral aspect of his R knee, his ligaments were intact, and he did have a positive McMurray sign (indicative of lateral meniscus tear).  We did X rays of his R knee, made him NPO, and gave him Voltarin IM (a medicine I wasn’t familiar with, generic name diclofenac, an NSAID).  The X rays of his R knee revealed the surprise that Dr. Mitchell (ED doctor) had already predicted. He had an R femur fracture/epiphyseal lysis (a fracture of his thigh bone through his growth plate). I had NEVER seen something like that before!   We called the Orthopedic doctors and sent him to St. Ann’s Bay.   




On Thursday, there was a well clinic at Annotto Bay.  Kasey and I enjoyed the plethora of adorable Jamaican babies who were primarily being seen at their two week and 1 mth check ups.   Both Kasey and |I were humbled by the trust that these parents placed in us…we wore stethoscopes, so we must be doctors.  We were able to give good anticipatory guidance about umbilical hernias, fevers, and no free water!

Thursday afternoon, we again went to the A&E department.  Kasey saw infantile dyschezia, while I saw a 15 year old F with diffuse abdominal pain (started periumbilically, and radiating to RLQ) concerning for possible appendicitis.  X rays of the abdomen were done and showed a nonobstructive bowel gas pattern.  I successfully obtained bloodwork, and started my first IV here in Jamaica!  When the IV fluids started dripping down the tubing, I knew the IV was good and I was proud.  In Jamaica, ED physicians regularly obtain their own bloodwork and start their own IVs.  However, in America it is very different.  I realized how lucky I am to have IV teams, scheduled phebotomists, or ED nurses willing to place IVs and obtain bloodwork.

Today we are at Port Antonio, and it rained this morning.  Kasey says that means that fewer patients will come.  We will have to see what happens next.   

I can’t wait for what the next week will bring!