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I can’t believe that this experience is almost over.  Stevie and I have been so grateful for this month and are so sad when we realize its coming to an end. 

Wednesday and Thursday were our last days at Annotto Bay Hospital.  On Wednesday, we helped with patients on the pediatric ward.  Per usual, the morning was filled with interesting cases and great discussions led by Dr Ramos.  In the peds ward, there was a 1 day old 26 weeker who was doing surprisingly well.  At 900g the child was doing fabulous, maintaining good oxygen saturation without being intubated and maintaining his temp with an incubator that was duct taped closed!  We had an interesting talk on rounds about fluid management in neonates and the ways that things are done both at home and here.  Although we knew we were returning to Annotto Bay on Thursday, Stevie and I were both a little sad saying goodbye to the doctors we had worked with on the wards.  Dr Blake, Dr Yandav, Dr Fisher and Dr Ramos have all been fabulous to work with here in Jamaica and we hope that our paths cross again at some point!!


Wednesday afternoon Stevie and I had our first exposure to cricket as we watched a high school match.   Jamaicans take their cricket games very seriously!!  I was amazed at the number of people watching and the loud cheers when the home bowler hit the wicket!!

Thursday was a busy day at Annotto Bay!  Every other Thursday is well baby clinic where any infants born recently return for one follow up with hospital physicians.   After that visit, if they are doing well then they are just followed at the community health centers for immunizations.  When Stevie and I arrived there was a huge line of mothers holding their infants waiting to be seen.  We quickly got to work seeing the adorable newborns.  Fortunately, we did see many healthy newborns who were breast feeding and gaining weight wonderfully.  I also saw 2 patients with supernumerary digits.  Interestingly, when I mentioned removal one of the mothers told me she wanted the extra digits to grow— she had also had supernumerary digits and was angry that her mother had hers removed.  Unfortunately, the extra fingers were already starting to turn purplish so I spent a great deal of time educating the mom about why they would need to be removed and referred her to surgery clinic.   I contemplated tying them off myself but due to lack of equipment and mom’s reluctance I decided the surgery clinic would be a better idea!! 

I didn’t want to forget to mention about some of the Jamaican culture we have learned about here.  Many of the babies seen here have “ascifnata” placed in their hair.  Stevie and I had no clue what we were looking at the first time we saw it!!  Finally one of the mom’s explained that it’s to keep colds away from the babies.  Apparently it doesn’t work for older people though so don’t go searching for ascifnata at the drug store next year during cold season!!  Also many of the babies have red bracelets on that look like hair bands.  The nurses told us that many of the mom’s will get angry if you take these off the infants because they are placed there for protection and to ward off evil spirits also called dunny’s.  No matter where you are in the world, culture will play a role in your medical care!! 

I also wanted to make sure that Stevie and I mentioned our gratitude for Dr Ramos.  Dr Ramos is one of a very small number of pediatric trained physicians here in Jamaica.  After clinic he spent a long time explaining the Jamaican medical training system to us, as well as how the hospitals function on a day to day basis.  He was also curious about the US system and details involving the residency program.  Dr Ramos is an excellent physician who constantly challenges you to push your knowledge base.  He is a great teaching physician who is wonderful for any learning physician to get to work with. 

Our afternoon at Annotto Bay actually brought us back to the peds wards where we helped Dr Yandav with procedures.  We were able to start IVs and perform femoral sticks for necessary labs.  In Jamaica, the physicians, not the nurses, start all IVs and perform all necessary labs.  Stevie and I both love procedures and wish we had more opportunities to perform basic procedures such as starting IVs at home.   This rotation has been a wonderful opportunity to help patients in need while also learning procedural skills from physicians who do these basic procedures day in and day out.  Although Dr Yandav disagrees, he is a wonderful teacher of procedures and Stevie and I both were successful at the procedures because of his advice!!  These hints are things I will continue to use while practicing in the US.  Another advantage to performing procedures in the afternoon was that Stevie and I were able to say goodbye to many of the fabulous nurses we have worked with on the wards!!  These people have huge hearts and we will miss them!

There is a soccer field right by the hospital.  Well a soccer field, cricket field, whatever you want to call it.  I love soccer and some Jamaican kids are amazing.  It’s clear that they’ve grown up with a ball on their foot!!

Unfortunately, the ride situation home from Annotto Bay can be much more frustrating than at the other hospitals we work at so we are getting back to our resort way later than usual.  Stevie hasn’t felt great today but we’re hoping a relaxing ride home will help her feel better.  Keeping our fingers crossed that later on we’ll be enjoying the great food and live music that we’ve become accustomed too.

Still feeling so blessed,
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Friday was spent back at Port Antonio Hospital.  Stevie and I decided to switch it up again– her going to the A&E and me going to clinic.   I was really looking forward to the complex consultant cases Stevie had seen the week prior but unfortunately it started to rain again on Friday as well.  We were told when we first got here that Jamaicans don’t like to leave their houses when it is raining and I think that must be true because I had my first slow morning!!  At home I would kill for a morning like that but with access to care so limited here, I was chomping at the bit for more patients so I joined Stevie in the A&E.  The rain didn’t keep patients out of the A&E!!  Stevie and I both had a busy day seeing several common pediatric complaints– viral processes, strep pharyngitis and a few lacerations as well.  I mentioned earlier how Jamaican physicians learn to rely on their history and physical exams more than anything else– volunteering here is a wonderful opportunity to pick up on these exam skills.  I saw a 6 year old little boy with 2 days of fever, sore throat, headache and vomiting with no cough or respiratory symptoms.  He had large tonsils with exudate noted, a white strawberry tongue and even pastia’s lines in his antecubital fossa— I didn’t need a rapid strep to confirm this was strep pharyngitis!  No lab tests were ordered and I was able to send him home with a 10 day course of amoxicillin and maternal education about keeping him hydrated.  I finished my day by seeing a newborn in the maternity ward that I was asked to evaluate because the mother was VDRL positive and meconium staining was noted at delivery.  In addition to this the infant was noted to be mildly tachypnic with nasal flaring so the nurses in the maternity ward had placed him on oxygen.  There is not pulse oximetry available in the maternity ward so we had no way to document exactly what his O2 sat was.  When I saw the infant (about 1 hour after birth) he looked well.  The differential included congenital syphilis, TTNB, Meconium Aspiration syndrome vs congenital heart defect.  The general physicians asked me how we handled meconium deliveries — although the infant was improving they were planning on a gastric lavage to prevent vomiting.  I explained that we don’t do that back home and explained our process for meconium at deliveries.  The 2 generalist and I then had a great discussion regarding congenital syphilis and what is medically indicated when mom states she was treated but we have no documentation of this.  It was a great learning opportunity for all of us!!!  Ultimately we decided to treat the infant with PCN until lab results returned and admit him to the peds wards for monitoring of his respiratory status.  Oh and we didn’t perform a gastric lavage!!  I’m curious to see what happened with that little one when we return next week!

Friday night was the first night that we ate dinner at 8 Rivers which is the nicest restaurant here at Couples Resort.  We were treated to an amazing 5 course meal and wonderful wine!  We left stuffed but happy and spent the rest of the night enjoying the live music on a beautiful Jamaican night!!

On Saturday we were excited to spend the morning scuba diving but unfortunately the weather did not cooperate and we weren’t able to go this weekend– hopefully we’ll be swimming with the fish next Saturday!  Jamaica is such a beautiful country even on a cloudy, rainy day so we were still able to have wonderful day despite the weather!!  We went back on the catamaran cruise in the afternoon and had another wonderful trip.   It was the same crew as our previous cruise and they all remembered us and treated us like old friends from the start.  We spent the afternoon laughing, dancing and enjoying being out on the ocean.  Even with the occasional rain showers, that is hard day to beat!! 

 Sunday was a beautiful tropical Jamaican day!!  After the last Saturday Stevie and I were well prepared with lots of sunscreen and we had a fabulous day playing in the ocean.  We even went kayaking around the island.  It was so much fun that we are already planning our next kayaking trip back home– that or we’re going to be on amazing race.  Do you think they’d give us time off from residency to compete?? 


We spent the late afternoon treating ourselves to a massage at the spa here at Couples Resort.   The amenities here really are too good to be true and the massage was one of the best massages I’ve ever had!!  I’d highly recommend it to anyone staying here at the resort.  After the massage we showered and got ready for another fun night with great food, good wine and live music.  Because it was St Patty’s day back home we wore our green out to celebrate.  No green beers here in Jamaica but it was still a great night!!

I can’t believe we’ve already been here 2 weeks.  I can’t wait to see what the rest of this trip has in store…


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Stevie and I decided to blog every few days so here is our next update.  This rotation continues to be amazing.  It’s a great opportunity to help people  in need, sharpen your physical exam skills, learn from experienced clinicians and enjoy the beautiful country of Jamaica.  Friday was our first day at Port Antonio.  This hospital is over an hour away but the drive is breathtaking in areas– you can truly see multiple aspects of Jamaican culture en route.  When we got to Port Antonio, I took care of all the kids in the A&E and Stevie went to clinic.   There actually weren’t supposed to be peds patients in clinic on Friday but because Issa Trust has done such a great job of bringing in pediatricians, the community has learned we are now there on Friday.  As soon as word spreads that the pediatrician is there, the patients arrive.   Stevie took care of many interesting rash referrals from simple vaginal candidiasis to disseminated scabies to a complicated rash which was likely super imposed with a staph/strep bacterial infection.  Often times these rashes have progressed past stages we see in the US.  She asked several of the patients to return next week so we could follow up on their progress.  Look at that continuity of care even while we’re in Jamaica!!  In the A&E I saw several typical pediatric emergency patients — asthma exacerbations, gastroenteritis with mild dehydration and an interesting 8 week old with a large lateral neck mass whom I referred for an ultrasound and asked mom to return with the results.  The physicians and the patient families are very appreciative of our being there.  I had two of the physicians I worked with explain to me how helpful it would be to have a pediatrician on staff at all times but unfortunately in Jamaica that’s just not feasible.  All the physicians there are fabulous but they’re not pediatric trained and they are super busy with 3 of them covering almost the entire hospital.  It’s a clear that having an extra set of hands on deck can really help!!  I had one mother tell me that she’s wanted to see an actual pediatrician for so long and was so happy to hear earlier that week that we were coming on Friday!!  One final note about Port Antonio that I don’t want to forget to mention– it’s beautiful and Stevie and I went to explore the city during our lunch break.  It’s bustling with life and unfortunately we didn’t quite make it to the pier (we had to get back to the kiddos) but perhaps we’ll have icecream on the pier next week!!

This past weekend was the best weather we have had in Jamaica yet!!  Although I will admit Stevie and I both got a little too much sun on Saturday!!  Our weekend started Friday night with a lobster dinner at a fabulous restaurant at the resort.  After eating way too much for dinner, we enjoyed live music and delicious wine– the combination definitely had us dancing in our seats!  Saturday we spent the morning laying out on the beach relaxing and then took a catamaran  cruise in the afternoon.  The cruise was perfect– tasty drinks, driving the boat, swimming in the ocean and completing it all with an awesome dance party with all the others on board.  On Sunday we participated in our first excursion away from the resort when we went ZipLining through a mountain rainforest.  This was perhaps the coolest thing I have ever experienced.  We took a sky walker to the top of a mountain, went on 5 zip lines and then went “bobsledding” around the mountain.  This experience was amazing and I recommend it for anyone in Ocho Rios!!  The weekend concluded with an amazing Asian dinner at Bayside restaurant followed by a gorgeous night on the rooftop bar.  I continue to be grateful to Issa Trust for not only allowing us to take care of these adorable kiddos but also to get to experience this country in a way that otherwise would have been impossible during residency.  It’s true in Jamaica, no problems man!!

Now back to the real reason were here, to help the children of Jamaica.    Monday was spent back at Port Maria.  The morning started out much slower then it had the previous Tuesday but by the end it had picked up and we’d seen plenty of rashes, ear infections, respiratory infections and viral gastro.   We also saw several of the follow up patients from the weekend.  The afternoon can be challenging because often the lab closes and the pharmacy closes well before you are done seeing patients.  Sometimes you feel like you are treating patients without all the information.  However, you learn to trust your physical exam and your gut (sick vs not sick).  You also have to educate parents about what to watch for at home and when to bring the child back.  The same is true back home but it sometimes feels magnified here!  All  in all, another great day.

We just got back to the resort and it’s gorgeous today so we’re off to enjoy this weather!!

Sunburned but still happy

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Last week at Port Antonio Peds clinic we were referred a patient from the health center. He was a 6 month old male who was referred to us for concerns of hypotonia. Upon further history, we learned he was a term baby, growing and thriving, and mom had been concerned about his tone for quite some time. The nurse at the health center also noted some nystagmus at rest. On our exam, he was not dysmorphic, HEENT, CV, Lungs, Abd were normal, though neuro was not. He was hypotonic diffusely, though normal muscle bulk. He was also hyporeflexic in all major muscle groups. His Fontanelles were still open, and maybe a bit on the wide side. His eye exam was significant for horizontal nystagmus at rest, and exagerated with eye movement. His pupils responded to light and he blinked to light, though did not focus or react to any visual stimuli.
We had many concerns about this baby, specifically his tone and whether or not he could see, and he obviously needed some further testing, thought where to start? Of course the cell phone server was being worked on that day, so we were limited with our contacts, though I (Chris) did manage to get in touch with Dr. Judy Tapper in Kingston. She agreed that the baby needed to be seen, and didn’t want to suggest any tests until she saw the patient. Mom was very concerned about cost and had very limited resources. Dr. Tapper was very friendly and helpful, though explained that she was the only pediatric neurologist in the country of Jamaica, and therefore was very busy. If the patient wanted to go to the free clinic at Bustamante Children’s Hospital, there was a 6-9 month waiting list. She could go to Dr. Tapper’s private office, though would have to pay out of pocket for the visit (About $9500 Jamaican Dollars – roughly about $120 US) I explained all this to mom, and she understood, I told her to make the appointment at the free clinic, though stressed that if she could go to the private clinic, this would be preferred. As this was not an emergency and I had no true reason to admit the patient, these were the options. Mom understood and said she would try to figure out a way to find the money, and would make the appointment at BCH in the meantime, and would follow monthly at Peds clinic until further testing was done.
This case was interesting, though made us a bit sad, as if this boy and mom had more resources, she may get some answers a bit sooner. Hopefully it all works out and mom gets the answers and help that she needs, though at this point I’m not sure I’ll ever know how it turns out….
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4 month old male who was discharged from the ward 2 weeks prior for resolved bronchiolitis. On the day prior to discharge, he developed a rash on his left leg. They were told it was probably a reaction to one of the medications (he was on Azithro and Augmentin) and gave him some diphenhydramine which did not change. The rash then spread to other parts of his body like his other leg (and soles of feet), both arms, left shoulder, and abdomen. The rash was obviously pruritic, though he was otherwise comfortable and non-toxic. The rash appeared to be in clusters, though didn’t seem to follow a dermatome or other pattern that we could identify. The lesions were mixes of papules and vesicles vs pustules? Hard to really say what it was. Mom said it seemed to be spreading slowly over the past two weeks. Any thoughts???? We were between scabies and varicella, though we’re sold on either. Our plan was to treat for scabies and have her follow in a week, or sooner if it got worse.
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Well, hard to believe we’ve already been here two weeks and our trip is half way over. The sites are becoming more familiar, the accents are becoming clearer, and we are starting to feel the exhaustion. Though,having said that, we are learning so much about the people, the healthcare system, and the island it is just great! We wanted to hi-light a few of the cases that we thought were interesting over the past week.

1. Crush injury to the finger. Stephanie tried to save the finger tip of a 2 year old girl who got crushed by a bucket. I (Chris) held the best I could. What we wouldn’t have given for a papoose and a digital block! Though all in all, turned out ok, and mom returned the following day for an Xray and wound check!

2. Testicular swelling. I (Chris) saw a 3 year old boy with 3 days of unilateral testicular swelling that mom thought was occasionally painful. His exam was non-tender, though definite swelling and firmness on the right. Testicles are on my list of “don’t mess around”, so I knew he needed an ultrasound – though where to send him? Port Maria does not have US, and Annotto bay likely didn’t do scrotal US. The NP told me just to send them to a private ultrasound place and they would bring the results, though who knows how long it would take – and if it was positive, then what? So, I grabbed the yellow pages and called Bustamonte Children’s Hospital in Kingston, ID’d myself as a doctor, and asked to speak to someone in Urology. Within a minute, I was transferred to the head of urology and surgery Dr. Abel, and he couldn’t have been nicer. He agreed to see the patient the following morning and do an Ultrasound there, and mom was happy to take her son to Kingston. Glad this one worked out!

3. An interesting rash (see next post)

4. Chronic Diseases: I (Chris) saw a lot of patients for chronic disease follow up. While I relish at the opportunity to see asthmatics and give them education and stress the importance of the “brown pump” (QVar) and “blue pump” (Ventolin), there were a few that I wasn’t as comfortable with. I saw multiple patients with Sickle Cell Anemia for their check up, they looked great and I just continued their prophylactic antibiotics and folic acid. I also saw a rheumatic heart disease check up, though he was in relatively great health, I was releived when mom told me he was going to see cardiology next month!

5. Holy Murmur! Stephanie and I saw a child (12 year old male) in the A&E at Port Antonio for follow up labs for syncope and Mom said, “oh yeah, he’s a heart patient”. Gulp. It sounded like his syncope 3 weeks ago was likely due to some dehydration and vasovagal activity, though we needed to know more about his heart. She said he had “a hole” in his heart, was seen in Kingston as a young child, and actually went to Richmond, Virginia for evaluation 4 years ago. Mom said they didn’t do an operation, and she was never really told what kind of “hole” it was. Hmmm.. His exam was impressive, with a true 6/6 holosystolic murmur – yes, we didn’t need a stethoscope. We assumed he had a VSD, and as there were no signs of failure and he was doing great otherwise, we thought it best that they reconnect with Cardio in Kingston and mom agreed.
We also stressed the importance of follow up and discussed signs of heart failure.

Until next time!
Peace Mon!
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Yesterday we went to Port Antonio Hospital. This hospital was in Portland Parish, about a 2 hour drive through winding, hilly, jungle roads from our hotel. When we arrived (thanks to our very polite ride and hospital administrator, Mr. Campbell), we were warmly welcomed and put to work. We tried to start in the Peds ward, though the docs had already rounded for the day, so we went to the outpatient clinic.
In the Jamaica, Pediatrics is considered a subspecialty so we had a lot of patients that were referred to us from general practitioners. Again, we saw lots of rashes, URI’s, and scalp infections. We also saw two patients that we felt needed referral to ENT. One was a 2 year old male with language delay likely secondary to his tongue tie that was never corrected, and one 3 year old female with significant tonsillar hypertrophy and obstructive sleep apnea. Luckily (after a few phone calls and some very helpful nurses) we found out that there was an ENT clinic in Kingston at Bustamonte Children’s Hospital every Monday – in luck! We filled out referral forms and the parent’s seemed happy that something was hopefully going to be done.
After the Clinic and a quick lunch (we’re getting really good at making English Muffin sandwiches at the breakfast bar and stowing them), we went to the A&E to help out. We saw a mixture of patients, but a few stood out. We saw a 5 day old male that had some eye discharge, his eye looked fine and just had some drainage dried on his face. We thought this was maybe some lacrimal duct stenosis that was very normal, or maybe a very superficial infection, regardless our plan was some warm compresses and antibiotic eye drops. Though when we ran this by the attending doc, he said that he would admit this patient for 3 days of IV ceftriaxone, and erythromycin, tetracycline and neomycin eye drops. He could tell I looked surprised, and I said that that wasn’t standard practice in the states, and Ceftriaxone isn’t approved for a baby his age. At first he acknowledged my plan, but in the end he wanted to be “safe, rather than sorry” and admitted the patient. I was glad he entertained my input for a bit, but in the end it was his decision. Any thoughts about this from other docs that have been here and treated Opthalmia Neonatorum – they do get “eyes and thighs” in the deliver room.
Another patient we saw was a teenage girl with syncope, and after a good H&P we felt that this was orthostatic changes due to dehydration and she probably just needed some fluids. We told the nurse that we wanted to give her some fluids, and she handed me a glove (for a tourniquet) a cotton ball soaked in alcohol, and an IV cannula (one very different from the IV’s in the sates). Stephanie searched for a vein while i primed the tubes, and thankfully Stephanie got the IV in one try and we made it work! While this may seem like a small feat, we are so spoiled with our awesome nurses at Akron Children’s, we were both holding our breath!
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Yesterday we went to the Annotto Bay Health Center, an outpatient clinic in St. Mary’s Parish that is peacefully located on the water. Although the staff did not know we were coming, they were very welcoming and we knew we would be of use as there were rows of Moms and Children already lined up. Again, we saw a mix of URIs, rashes, Tinea, and constipation, but there was one patient that made us both skip a heartbeat, if only for a minute.

A mom was sent over to us with her 3 month baby from the nurse. She was quiet, though polite. She said that after her baby was born, he had to be admitted for a few days because he was breathing fast. The breathing was improved, though mom reports that he had a chest x-ray and EKG that per mom “showed that one side of his heart was bigger than the other” – cue Oh Crap! She was referred for an echocardiogram, though she could not afford it, and was subsequently referred to a cardiologist in Kingston that had an available appointment in September (7 months from now!). Upon further history, the baby was doing well, feeding and thriving (with occasional sweats), no pallor or cyanosis, and developmentally appropriate. His exam did reveal a very soft mid-systolic murmur at the apex and LLSB, though no signs of heart failure. Our portable pulse ox (Thank God and Dr. Gunkleman from Akron) showed sats of 96%. We were reassured by our findings and planned to look up the Xray and EKG tomorrow when we go to the hospital that the tests were performed. Our thoughts were that this baby was probably fine and maybe had a small VSD, and his EKG probably was just RVH (cue Dr. Bockoven, “RVH in a newborn is normal!” mantra). We told mom that we would check on all this and for her to follow up with us in 1-2 weeks, and to keep her appointment with cardiology in September. In the end we were much more comfortable, but what a scary chief complaint!!

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Greetings from Jamaica! Let’s start with introducing ourselves. We are Chris and Stephanie, 3rd
year pediatric residents from Akron Children’s Hospital in Akron, OH. We are so excited to be starting our time
with Issa Trust Foundation, and sharing our experiences with the readers of
this blog. Before we get into the clinical
aspects of our trip, let’s first touch on the AMAZING accommodations at Couples
Tower Isle. The staff here, along with
Diane Pollard, have truly made us feel welcome and have made this a relatively
seamless start to our month.
was our first day at Porto Maria Medical Center. The center is very busy, having inpatient
wards (adult, maternity, and pediatrics), a busy A&E (Accident and
Emergency Room), a busy walk-in health clinic, and a pharmacy. We were warmly greeted by the staff, nurses,
and other physicians there and quickly got to work. We split up right away, with Chris working in
the Outpatient Clinic and Stephanie in the A&E.
At the outpatient clinic, I (Chris)
saw a lot of general pediatrics issues. Main problems I encountered were Tinea
Capitis, other various rashes, URI’s, and GI worms. After only a few patients, my training kicked in and I started to feel more comfortable with the system. Right now my biggest obstacle is learning
what resources are and are not available.
It’s all well and good that I know what the problem is and how to treat
it, though if the pharmacy doesn’t have the treatment I order , then what good
am I doing. As I get more familiar with
our resources, I feel that my nerves will be more settled. Thankfully the staff is very welcoming and
patient, and is very open to questions.
(Thanks to Dr. Hines for the dose of Albendazole – Stephanie had the
formulary in A&E!)
In the A&E, I (Stephanie) was
sent the less acute patients, the ones who did not require nebulized treatments
or IV fluids. As I sat there waiting for
the first patient to arrive, I felt the nerves building up. The first patient had complaints of a
possible seizure, which I am normally comfortable with, but found myself having
a difficult time since I did not what resources were available for testing or
work up. After I had a few patients come in with URI
and asthma complaints I started to get the hang of things and felt more
comfortable. Dr. Facey in the A&E was a great resource
to me, especially when I wasn’t sure what to do with Ventolin Elixir or xray
turn around time. Deworming was a big
complaint which I fully embraced and prescribed mebendazole. The parents seem open to education,
especially on asthma. I even filled out
an asthma action plan (which would make Chris, our future pulmonologist,
Our first day is over, we are
feeling less nervous, but still getting comfortable with the resources. We can’t wait to see what the rest of the
week brings. We will be blogging again
soon! Ya mon!
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