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After a good nights rest and some medication both myself and Stephanie felt much better. It took awhile to get going on Friday but the Jamaica sunshine is a great motivator.We were unable to go to Port Antonio on Friday which made us both sad because we’ve seen so many great cases there and their need for Pediatricians is perhaps the greatest. Dr. Ramos only sees pediatric patients on Tuesdays and he has to limit the number to 15 given his other duties. Now that the community of Port Antonio is catching wind that we are present on Fridays the patients come in good number.

I have to say we took our last weekend by storm. We first decided to lay in the sun and relax as both of us had not felt well for the pat 24 hours but after watching everyone else on the resort participate in activities we were both itching to do something. We decided on snorkeling and had a blast. We saw tons of fish, my favorite were these amazing light blue ones that reminded me of Dori on ‘Finding Nemo’ and Stephanie loved the yellow fish with black stripes which she thought kind of resembled Nemo 🙂 She was also lucky enough to see a sting ray! I was soooojealous!! We were pretty exhausted after this one little excursion so we returned to the room for some rest and nearly slept through our dinner reservations made over a week ago. But no worries, we rallied and got ready in no time. After all…you can’t pass up the amazing food here on Couples resorts.

Saturday we awoke to go train for scuba diving. We had been looking forward to this the entire trip but typically they only do classes on weekdays. We first did a swim test (you have no idea how hard 4 laps
in pool can be) and luckily we both passed! We then watched a 30 minute video about the equipment and safety instructions for scuba diving. Then we were off to the pool in our gear. We like to think we looked fashionable but our wet suits were a little awkward fitting to say the least. We practiced in the pool for about 45 minutes but unfortunately I had a cold and was unable to clear my ears at just 6 feet (the depth of the pool) and that’s not safe for scuba diving. Steph and I had a blast practicing in the pool and our instructor was phenomenal. I guess I’ve just been loving up on too many sick Jamaican children in the A&E 🙂 Since scuba was out and we were feeling adventurous we decided to go skiing behind the boat. We’ve both have been water skiing behind boats in the lake but never the ocean so we were beyond excited. It was late morning and the water was a little choppy but we both managed to get up twice and had a blast. Our boat driver Kenneth was so nice and knew exactly how to pull skiers out of the water.

 Later that afternoon we went on the Catamaran cruise (our 4th time…we know, a little excessive) but we love the crew and the peacefulness off being out on the ocean. Plus we met some great people this time who were spending their anniversary here and had some great conversation. The waves were a little crazy and Stephanie and I had a few scares sitting on the front of the boat (I lost my prized blue aviator sunglasses!!) but all in all it was a great time. I found myself in a back flipping competition off the boat with one of the staff, Odain, and I like to think I won. He was much more fearless than me though and his one foot back flip was a crowd pleaser. After returning back to the resort, we participated in a Reggae Dance class on the beach. I’m sure we provided great entertainment and a lot of laughing for those watching. We again had a great dinner and ended our night by skyping our fellow 2nd year residents. This weekend was our annual retreat and we were sad to miss it but we like to think we were there in spirit. After much laughing and telling them about our experiences here we hit the sack looking forward to our last weekend day on the resort.
We woke up Sunday and climbed Dunn’s River. We had both done this before, Stephanie 6 years ago on a cruise and me on my honeymoon 4 years ago, but we were up for a 2nd trip. The sun was out and we again
were feeling adventurous. Our bus driver, Gary, had to be one of the funniest people I’ve ever encountered. He gave us a full tour of Jamaica on our way to the falls telling us about everything we passed from an Electric Store with the motto “stronger for longer” (you can imagine the jokes made) to the only radio station on this side of the island called ‘Irie’ which plays only reggae music. He then gave us a run down of the geography of Jamaica, explaining that we had passed through 4 parishes from the airport to the resort which resides in St. Mary (interesting fact is that Port Maria where we work Monday and Tuesday is the capital of St. Mary). We arrived at Dunn’s River and after very strict instructions from Gary regarding vendors and video purchasing we were off. It was a great group of people from the resort and we had an absolute blast. Walking hand in hand with a bunch of strangers up a waterfall doesn’t sound like the safest thing but we were taken care of by our guides and each other. From falling backwards into the water to going down a natural slide made in the rocks we were smiling the entire time. We don’t have pictures because we forgot to bring a waterproof camera but it was beautiful and a great time overall! We got back to the resort and spent the rest of the afternoon relaxing in the sun and making tie-dye shirts!!! I was much more excited than Stephanie as tie-dying has long been a passion of mine, just playing, kind of.  We made late afternoon spa appointments for a facial and pedicure, both of which were wonderful and a must if you get time. By the end we were so relaxed and thankful for the much needed pampering. We then headed to dinner and like always the food was amazing. We also met this great couple who were on their 13th trip to this resort and had a son in his 2nd year of medical school!! We had great conversation with them and ended the dinner stuffed!


Today was our last full day in Jamaica and Stephanie and I both woke up sad. We pumped each other up at breakfast and reminded ourselves we were dedicated to returning. The children of Jamaica have a huge piece of our heart and the need for their care is immense. We spent the day at Port Maria, which is perhaps my favorite hospital because we see the most volume there and the nurses are phenomenal and extremely helpful. We learned from our driver this morning that Port Maria serves 66 communities and 8 surrounding towns. No wonder the volume is so great! We also learned that they have no ultrasound machine or tech in the entire hospital. You must be referred to St.Ann’s which only accepts 2 patients a day. We are blessed to have so many resources in America, this trip has taught me never to take that for granted. Stephanie spent the day in A&E and myself in clinic but upon our arrival we were met by a concerned mother. I had seen her 3 year-old boy last Tuesday for an ear infection and possible right-sided inguinal hernia. Mom’s description of a bulge while crying or coughing was consistent and on my exam I could appreciate a bulge during valsalva. I made a referral for pediatric surgery at St. Ann’s which only holds clinic Tuesday and Thursday morning but mom had not gone. I also gave her instructions for seeking immediate medical treatment if the bulge became painful and constant, there was color change over the area, abdominal distention, or uncontrolled fever. She followed those instructions thankfully and today she explained that the bulge had been persistent for 2 days and he was now limping while he walked complaining of pain. Stephanie and I were absolutely concerned for incarceration and after our physical exam and a discussion with the A&E physician the plan was for immediate transfer to St.Ann’s to be evaluated by surgery. What an eventful way to start the morning! Clinic continues to be busy here at Port Maria and I saw many skin infections (a kerion being a new one) and lots of colds and ear infections. I had an especially adorable 1 year-old who was intrigued by my stethoscope. Sadly his newly erupting teeth posed a great threat so I eventually had to take it back but not before some great pictures!

Stephanie was in the A&E and had another appendicitis scare! Once again the lab was down so she only had an abdominal X-ray to help her in addition to her physical exam. And guess what? Constipation strikes again. She also had a little girl brought in by her Aunt for breathing difficulties. On exam she was wheezing with crackles on the right lower base and her vitals on presentation revealed hypoxia. She was placed on oxygen immediately and given a breathing treatment. Unfortunately she didn’t improve and was admitted to the hospital. She was treated with CTX and continued on oxygen with the admission diagnosis of bacterial pneumonia. Most of her labs and CXR will have to be done later since everything had closed down for the day.

Our last drive home from work was gorgeous like always. After you get out of the town of Port Maria it’s just ocean for a few kilometers and it’s breathtaking. Nothing can ever beat it.
Tonight were packing (and maybe crying) as we prepare to leave in the morning. We can’t believe it’s already over. We’re planning on going to the beach party tonight followed by Margaritaville with the rest of the resort-goers 🙂 it should be a great ending to a wonderful trip!

Fully blessed and sad to leave,
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I can’t believe this is our last full week, it’s flown by. The drive to work is going to be hard to beat when we return home.

We started at Port Maria on Monday and we were busy! Stephanie was in clinic and saw many rashes, infected scabies being the most common.  After consulting with each other and the physicians we learned they treat with a combination of permethrin, augmentin, and mupirocin. Scabies is not that common in our setting at home and seeing it infected is even less common. Once again our physical exam skills are being sharpened. I spent the day in the A&E and felt overwhelmed with the number and variety of things I saw. At one point I had a little girl in the observation area receiving IVFs, 2 children in the lab followed by X-rays, and 5 patients waiting outside. It felt like home and my multi-tasking skills were at their best. Perhaps the most challenging but revealing case was an 8 yo male who presented with complaints of HA, sore throat, anorexia, emesis, and abdominal pain for 1-2 days. He was febrile to 102.4 on arrival and did not appear to feel well. After a detailed history I learned he lacked URI symptoms and combined with my physical exam of cervical lymphadenopathy and an erythematous oropharynx I was leaning towards the diagnosis of strep pharyngitis. I had one hold up though, his abdomen was extremely tender and he demonstrated guarding in the RLQ without rebound. Upon questioning he kept pointing to his umbilicus when I asked where it hurt the most. We all know appendicitis in a child can present atypically but pain that started near his umbilicus, tenderness in the RLQ, high fever, anorexia, and emesis seemed a little too classic to let him go with just a script for amoxicillin. So I started delving into more history asking mom about his bowel habits, desperately looking for another cause of abdominal pain. He did exhibit some signs of constipation so I decided a KUB and a CBC could help me make a decision. A KUB to look for constipation and even free air if he had ruptured his appendix (unlikely given his exam) and an elevated white count, again to help rule out appendicitis. We were unable to get the CBC but the KUB showed constipation!! By that time he was running around outside and I felt very comfortable sending him with a course of amoxicillin for pharyngitis and mineral oil for constipation. Long story for a simple diagnosis but it goes to show that you can’t ignore classic signs of something you can’t afford to miss, appendicitis. It also shows that constipation in children is painful! Always keep it in your differential!

Monday nights at the resort are “Beach nights” and they make this wonderful dinner and have appetizers and drinks and music outside. We haven’t yet participated in this awesome party but we did stop by and sneak a few of the appetizers. Our plan is to enjoy it our last Monday here which is this one upcoming.

On Tuesday we returned to Port Maria and switched our roles, Steph in the A&E and myself in clinic. Unfortunately the clinic had no available rooms for me so Steph and I shared a room. It was a busy day but we made the small space work. We saw over 30 patients together! Along with our ability to be efficient, our physical exams were put to the test. For visualization, we saw classic tinea capitis, diaper dermatitis, and more scabies. For auscultation, we heard many variations of wheezing as we had to frequently assess asthmatics after breathing treatments. For palpation, we assessed for fluctuancy of skin abscesses and I’m fairly certain we felt the “sausage” mass associated with intussusception. Other physical exam findings to note were strabismus and ptosis. It was a great day overall filled with a  huge amount of learning potential we definitely capitalized on. Today also brought continuity which is amazing. Steph and I were able to follow up with our little boy who’s finger was lacerated after a grease pan had fell on it last week. We repaired it and prescribed augmentin and mupirocin along with recommendations to keep the dressing clean and dry. But little boys being boys that dressing came back as dirty and wet as you could imagine. There was pus overlying the lac when we removed the dressing but I like to think our antibiotics and mupirocin helped keep the infection at bay. We ended the afternoon as we had done last Monday but Steph and I switched roles. I tightly held the sweet little boy in a chair while Stephanie removed the sutures and redressed it. It was quite the tear-filled experience for our little guy as he remembered the procedure room from last week but he still liked us afterwards. He’s coming back next Monday and continuing on antibiotics.

When we got back to resort we were exhausted from a full day and we spent an hour sitting by the beach just talking about the patients we saw that day, reviewing their presentations, and running our plans by one another. It’s such a blessing to have time after a long day to really process what you did. The opportunity to process rarely, if ever, comes when working at home. I think most residents would agree with me. By the time you’re off work you’re often so exhausted that the only thing you can do is eat dinner, shower, and go sleep as you prepare for the next day, especially as we’ve switched to shift work.  I cannot convey how wonderful it has been to just sit and talk with Stephanie about medicine. I know from our weekend adventures that medicine may seem to be the last thing on our mind as we return to the resort every evening but that’s honestly not the case. We both feel like we learned so much here and are appreciative for the much need down time.

We concluded the night with an amazing dinner at 8 Rivers and we even got fancy for the occasion. The food was delicious and filling and the waiter was shocked when we turned down desert. We then went to the main dinning area to enjoy some live music and found ourselves out on the dance floor in no time. From ‘We are Family’ to ‘YMCA’ we tore up the dance floor and made many new friends!

 Extremely blessed and thankful…S&S
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This opportunity continues to be amazing and eye-opening. We spent Tuesday at Port Maria and Steph and I switched it up…her going to clinic and me in the A&E. Stephanie was referred many patients from the Matron for complaints found during their well checks. Common things being common, she diagnosed pneumonia, otitis media, and many rashes. She was able to follow up with a patient I had seen the day prior who had fever without a source and was given IM Ceftriaxone and asked to come back. The great news is that he looked much better and was smiling and playful. It’s amazing that we’re able to have continuity here as the moms often have to walk long distances to the hospital. The people here continue to put smiles on our faces and it’s very apparent how much the mothers care for their children.

My time in the A&E at Port Maria was eventful to say the least. With the recent rain and “cold front” as the Jamaicans call it, I saw lots of asthma exacerbations. I did my best to educate each family and even found handouts about asthma in the clinic room. I sent two of them home with asthma action plans! The most exciting and challenging part of the day was a precious 3 year-old boy who needed his finger sutured. With no anxiolytic and only myself and Steph to hold him the process was extremely difficult but we got it done. Plus he is coming back next week for follow up.

Wednesday we returned to Annotto Bay Hospital and started the morning with rounds. We had extremely interesting patients and there was lots of good discussion not only about each patient’s treatment plan but about medicine in general. A little boy had been admitted the night before with 4 days of cold and cough symptoms along with 2 days of alternating lethargy and irritability. The interesting part of his history was that he had been given “bush tea” over the past 2 days. He’d received IVFs overnight and the leading diagnosis had been intoxication from “bush tea”. We learned on rounds that it’s customary, especially in the rural areas of Jamaica, for mothers to make tea from various bushes as a cold remedy. But similar to being in the US,  we have no idea how safe these herbal remedies are. We ultimately determined after much discussion, that “bush tea” intoxication is truly a diagnosis of exclusion given the lack of reported cases. With that being said an encephalopathy/encephalitis needed to be ruled out with an LP.  Soooo…if there’s a take home message to this story, it’s don’t give bush tea to your child!!!  We then finished up the day with Dr. Yandav doing procedures. We each performed an LP and drew blood for the lab. It was a wonderful day spent with sweet patients and great physicians.

We returned to the resort Wednesday night and rested a bit before having dinner at the Bayside restaurant (Asian cuisine). We had a delicious dinner and then we stayed up waaaaay too late to enjoy the steel band. They were amazing and full of energy. They played versions of popular songs like gangnam style and tons of Michael Jackson, my favorite. They had dance routines, outfit changes, and even did this crazy balancing stunt. It was incredible to say the least.

Today we spent the morning in clinic at Annotto Bay Hospital. Last week was filled with 2 week-old infants coming for hospital follow-up and weight checks but today we saw many older patients. Stephanie and I both saw many children with seizures, some with epilepsy on AEDs and others with febrile seizures. We both gave a lot of education to the families with children having febrile seizures, emphasizing that controlling the fever could prevent the seizure. Dr. Yandav joined in and made the very valid point that the seizures typically occur just prior to the fever or sometimes afterwards. His point was that parents should treat their child with either panadol (acetaminophen) or cataflam (diclofenac) at the first sign of warmth to touch. Interspersed between these patients was an asthma follow-up, phimosis, UTI, and well checks. The most exciting part of the day for me was following up with an infant I had seen just last week on the wards. The mom remembered me which made the visit all that more enjoyable. It’s amazing that here in Jamaica we are able to have continuity. While the morning was bustling, the afternoon was rather slow in the A&E which is proving to be the trend. I think with all the damage from Hurricane Sandy there is limited knowledge that the A&E is up and running and ready for kids. This did give us the chance though to follow up on our patients from the wards and it was really rewarding to know that all of the LPs performed yesterday were normal. It was also nice to see all the precious patients again too. We ended the afternoon with a snack from the Tuck Shop, the local eatery here at the Hospital. We had beef and cheese patties, curtesy of Dr. Marshall, one of the A&E physicians. We were warned that Jamaicans have heartier stomachs so we can only blame ourselves if there are negative repercussions from our eating adventure. It was totally worth it though…patties are delicious!

We’re heading back to the resort. It’s cloudy and cool here…maybe another cold from is moving in. After our late night watching the steel band we’re planning on naps and an early dinner. I say that but the idea of kayaking is being thrown around because even through our exhaustion we want to take advantage of the amazing opportunity we’ve been given. Well see 🙂


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So this is our first blog of the trip and Stephanie and I couldn’t of had a better first few days. I’ll admit the rain hasn’t been our favorite part but the country of Jamaica is so beautiful it makes up for it. I’ll start with our lodging which is too good to be true. Staying at the Couples Tower Isle Resort is amazing. It’s gorgeous, well-kept, and staff treats you like old friends. They all knew our names by the first evening and we were often referred to as “S&S” for Stephanie and Stevie. The food is plentiful and there is so much variety. The entertainment is full of flare and the music has tempted both of us to get up and make fools of ourselves after dinner every night. From crab racing to the steel band you won’t be bored.

Now to the reason were really here. The kiddos. Our first day of work was spent at Port Maria. Stephanie worked in a room off of the A&E (Accident & Emergency) and saw a good number of kids. She saw everything from ear infections, pneumonia, seborrheic dermatitis, and and chest pain. We should of brought an otoscope but they have one there and you can easily walk patients into the A&E to use it. I was in the clinic at Port Maria which was bustling with well child visits and vaccinations. I acted as the referring pediatrician and was sent any child with a medical complaint during their well check. I saw many URIs, pneumonia, eczema, tinea corporis, and even a septic hip which was referred for admission. They have basic lab work and radiology there which is wonderful because you can send a patient over and have them return with the image or results in real time. There are limitations especially with the pharmacy, for example they have no oral third generation cephalosporin but you can give IM Rocephin. Another challenge we faced was a common one in pediatrics, parental desires and concerns. For example, the child with the suspected septic hip had been see just 2 days prior and referred for hospitalization but the mom refused because she wasn’t allowed to stay. We resolved that concern by referring to St. Ann’s Hospital because parents can stay but the mom could not travel there until morning. Luckily we were able to give a dose of Rocephin along with a referral form stating everything we wanted done. The mothers in Jamaica are very attentive and great historians (which helps because you often can’t make out anything from the charts). They can tell you the exact age of their infant down to 8 months, 13 days. They can also list medications and dates of previous appointments with other physicians…all wonderfully helpful.

The second location we’ve visited is Annotto Bay Hospital which is located in a very rural area. We spent our first morning in their pediatric ward and they had 8 patients total, 2 being social cases (you don’t round on those). We saw a patient with epilepsy, one with nephrotic syndrome, and many premature babies. There was a great deal of teaching done on rounds by Dr. Ramos. We then went to their A&E that afternoon which is currently still undergoing revision after damage from Hurricane Sandy but is actively seeing patients. We walked into a physician treating an asthmatic who had already received 3 rescue salbutamol treatments and was still breathless. They were planning for steroids and admission just as we would in America. There were very few children that day so we were able to return to the resort where we participated in the spin class which kicked our butt! We followed the class by relaxing at the poolside grill and having cheeseburgers and delicious onion rings along with some Red Stripes. A little counterintuitive but hey…we’re in Jamaica, no problem man.

Today we returned to Annotto Bay for well child clinic. As we walked in there was a line of mothers and babies as far as we could see and we immediately got to work. We were able to share an exam room and bounce questions off of eachother which was great. As physicians you are constantly learning not only from your patients but your colleagues as well. Our number one goal with each newborn was to ensure adequate weight gain and I don’t think either of us saw any baby that had trouble with this. Jamaican mothers are dedicated to breast feeding and there’s little stigma to openly feeding in public. If the baby was healthy they did not have to follow up but they were reminded to take their infants to the health clinic at 6 weeks of age for their vaccines. We also saw many hospital follow ups and again the mothers were excellent historians in these cases. Our physical exam findings were sharpened today and we saw an infant with an ear tag and pit that we referred to receive an abdominal ultrasound looking for any renal abnormalities. We also saw a baby with ophthalmia neonatorum (aka bacterial conjunctivitis) that we treated with IM Rocephin, PO erythromycin and tetracycline eye ointment. We also saw a lot of umbilical hernias of varying sizes and spent a lot of time counseling moms about when they would resolve and signs of incarcerated bowel. We then finished up the day in the A&E and saw a child with 3 days of cough who one week ago was put under general anesthesia for circumcision. After a detailed history of no fever, URI symptoms, or history of asthma along with a benign physical exam we were left with possible post-extubation irritation of the larynx and treated him with a one time dose of decadron, like we would for croup back at home. We also saw a little boy with new onset enuresis and increased urinary frequency x 1 day who had a UTI. We did the urine dipstick ouselves after having him urinate in an old medicine container and then interpreted the results from colors on the urine dipstick. It was interesting. We also had to convert mmmol/L to mg/dL when interpreting his blood glucose. We left today as a transfer came in from Port Antonio which was a newborn with hypoxia who was grunting and retracting. History included meconium stained fluid, Apgars of 7 and 7, and SpO2 of 87% at 10 minutes. We would have loved to help admit the patient and wrote orders but they were already on their way to the ward. Our differential included TTNB (transient tachypnea of the newborn), meconium aspiration, congenital heart defect, or sepsis.

It’s raining here but were enjoying the inside of our resort and the wonderful food and beverages it provides. It’s been a great first few days and we can’t wait for more.

Tanless but happy 🙂 S&S
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