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Started Monday with our first work day at Port Maria Hospital. All of the staff was friendly and helpful. Thank goodness for Dr. Hayden-Peart!!! After being at work for more than 24 hours, she gracefully gave us a tour of the facility and a detailed orientation. It ended up being the A&E day of “twins”. We saw and evaluated 3 sets of twins by the end of the day. On Tuesday, we stayed in the A&E department and saw an array of patients including diagnoses of bronchiolitis, allergic reaction, broken arms and a patient with a history of G6PD deficiency. We ended our work day observing the ortho techs in action. On our way home with Ms. Nadia (one of the health administrators), she gave a great overview of the Jamaican health system. She gave great insight on programs or policies that could be implemented to help all involved – health providers and patients. “Ramos Rounds”: There were six patients on the ward this week. Two premature infants, one term newborn admitted for respiratory distress as well as children with status epilepticus, status asthmatics and bronchiolitis. We had an review discussion on atypical pneumonia, bronchiolitis and hyperbilirubinemia. Clinic was filled with some newborns, but mainly follow up patients for asthma and referrals. The A&E was filled with lots of injuries secondary to Sports Day (field day) or falls. Roxanne had the pleasure of placing sutures in the eyebrow of a very anxious and strong 6 year old girl…without any versed or EMLA cream or lidocaine in a very hot room. Thanks to Nicole and helpful mother she still has both eyes and symmetrical eyebrows. Dr. Wilson (Annotto Bay A&E) was awesome as usual! He always stops whatever he is doing to assist us with questions, obtaining supplies or navigating the health system. By the way he is super patient with you trying to get an IV in a 2 week old newborn (practice means less tears).  After it all, we ended the week with lots of hugs. Themes of the week:

• Everyone was eating, ordering or buying Bun and cheese – EVERYONE, EVERYWHERE – Happy Easter!
• Nicole discovered her love for June Plum juice
• Home addresses are more like directions (e.g. District, Parish. Blue and white house on the left after turning left at the Baptist church).
• You can make a spacer for albuterol (Ventolin) inhaler by cutting the bottom out of a Styrofoam cup or small water bottle.
• There is nothing better than a hug from patient.
• When in doubt call the pharmacy.

  Until next week, Nicole & Roxanne

On our first full day in Jamaica, we climbed the world famous Dunn’s River Falls all the way to the top. It was a great team building exercise to get us mentally ready for the week. The first few days of work have been filled with a mixture of interesting patients, new faces and trying to navigate systems-based practice in a developing country. Each morning, we awaken to melodic sounds from the birds outside of our windows as we prepare to start our day. Prior to reaching the health facilities, we spend 20 minutes to 2 hours traveling along narrow winding roads, but are privy to picturesque ocean views, scenic mountain greenery and the early hustle and bustle for local Jamaicans as they travel to work or school. Rounds on the ward: An ex-29 week preemie who is small yet vigorous laid in an incubator next to an ex-26 week preemie who has apnea and requires continuous resuscitation. Both babies are premature, both in need of ventilators not available, but the latter only survived six hours after we were first introduced to him. He is the fifth child lost for his mother (all born prematurely) and only to think if his life could be saved if the necessary equipment was available – all the incubators were being used at the referring facilities. Two other infants were discharged home having improved after meconium aspiration syndrome and neonatal seizures. The last two patients (4 and 10 years old) were admitted for sickle cell pain crises. The first child had a medical course complicated by a history of rheumatic fever with subsequent heart failure, now improved on aspirin and diuretics. The older intermittently cried out as he awaited his pain medication; no PCA’s are available. We did get to hold plain film radiographs for the first time!!! Accident & Emergency (A&E): The equivalent of the Emergency Room is staffed by non-pediatricians, but they were excited that we saw their pediatric patients (ages 12 and under). Trying to navigate the forms, resources available and medications in stock were the largest challenges. The staff was very friendly and helpful. Chief complaints ranged from upper respiratory tract symptoms to dehydration to imaging follow ups. The biggest concern by parents and health workers was H1N1 or flu as evident by the white masks worn by all the staff.   Annotto Bay Clinic: Thursday morning is typically newborn clinic and chronic disease (i.e. asthma) follow-ups. The day was commenced with torrential rain. A car we passed on the road had slid into the ditch and only a few mothers made it to clinic that day. We were greeted by a sea of infants, tightly bundled and breastfeeding in the waiting area as they awaited their first well baby visit. We were greeted by cooing smiles and their mothers gave us many thank-yous.   Port Antonio A&E: The busiest day of the week!!  After a two –hour commute, we were met with a room full of parents and children who waiting hours to be seen by a Pediatrician. We were directed into a small room (about the size of a standard bathroom) to see our patients. Initially we started with 8 dockets (aka patient charts), as we got settled in the nurse handed us 3 more dockets. It seemed like every few minutes a new patient were being added to the list. In about 3.5 hours we saw 13 patients. To close out the day we had to admit a 13yr old male with a textbook picture of new onset type 1 diabetes. Although we were able to get blood via venipuncture for initial labs, multiple attempts at IV placement were unsuccessful before departing for the day. As pediatricians we both have become accustomed to looking at the patient electronic medical record to follow up patient care even after hand-off, but here it’s more so,” I hope he will be okay” and that what we did was the right thing. It was surely a rough day; thankfully we were able to work as a team. Lessons Learned:

1. Dandelions supposedly help with preventing prostate cancer?
2. The pharmacy can close at any time, leaving patients having to return for medications or not obtain them at all if they have no means to travel back to fill their prescriptions.
3. Remember to ask if your patients have running water, a refrigerator or transportation to return for follow-up. This will play a role in clinical advice, management and decision-making.
4. “Yeh Mon” is used by as a noun, verb, adjective and greeting constantly by all the hotel guests and staff – absolutely hilarious!
5. Keep the patient charts in the correct order or your will corrected swiftly by frustrated parents, fussy children, and nurses.
6. Check in with the pharmacy for each location on the first time going to get a run down on what medications are available.

  Until next week, Nicole & Roxanne

I am half way through my time in Jamaica. It has definitely been an interesting experience. Mondays and Tuesdays are spent in the ED at Port Maria. There is a huge problem with space so the three of us have to share a single room. Wednesday mornings are ward rounds at Annotto Bay (if they have patients) followed by helping out in the ED. Thursdays are clinic at Annotto Bay and either consist of well checks or follow ups. Fridays are spent either at clinic or the ED in Port Antonio, the hospital with a view! Overall the hospital staff are gratful we are here and therefore are helpful and welcoming. Basic URIs , or “cold in the head Miss”, are very common. They have some very interesting cough syrups over here that the parents expect you to prescribe. They consist of a variety of ingredients including salbutamol or terbutaline, codeine, bromhexine, guaiphenesin, and menthol. My favorite one is called “Dawakof”, or “do away cough.” Along with the basic URIs, I’ve seen a lot of poorly-controlled asthma, tinea capitis, and scabies. Thankfully Ventolin inhalers are free from the hospital pharmacy and they even have an ICS! Unfortunately nebulizers are few and far between though making acute management of asthma in the ED a difficult situation. It also makes discharging a 2 or 3 year old home with an inhaler a less than ideal situation, especially when you have to just hope that the parent will spend the money on a spacer as these are not provided by the hospital pharmacy. I have possibly made some new diagnoses of sickle cell disease, although I may never know for sure. Newborn screen must not happen in Jamaica (I have yet to find out) but I have seen young children who appear to be in vaso-occlusive crisis with no diagnosis of SCD. My only clue is a Hb/Hct in the range of 7/22 with pending results for a “sickle cell screen” but no Hb electrophoresis.  Jamaica is in the midst of a hospital outbreak with Klebsiella and Serratia which has resulted in the death of 18 infants and many more infected. This seems to have resulted in multiple hospital inspections by the Health Department and results have been released but I have yet to read them. Hand sanitizer is hard to come by. Ear tips are washed and reused. The examination table sheet is only changed if absolutely necessary (I’m pretty sure this one would make the Health Department list of no-no’s. Available medications at the hospital pharmacy consist of a list that fits on two notecards. The wards are open air (and hot!) but thankfully the EDs and most of the clinics are air conditioned. Doctors do all of their own phlebotomy and IV cannulas, without EMLA or the papoose method, which makes for a very combative child. In contrast to this, accommodation at Couples Resort is lovely and comfortable. I’ve spent my weekends diving and relaxing on the beach, and trying to get used to being called “My Lady.” The hotel staff are lovely and the food is great. I actually feel guilty coming home to this after spending my days amongst patients who clearly have very little. Diane has been in town with some of her team and it’s been great to learn about the Issa Trust Foundation and everything that they have accomplished. I’m looking forward to seeing what my next two weeks consist of!