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21
March

Only one week left!!

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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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18
March

I can’t believe its already been 2 weeks!!

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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…

S&S




 
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14
March

Another great week!

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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 🙂

S&S

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11
March

It stopped raining!!

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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

S&S
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08
March

Procedures

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You will find that there will be many opportunities for procedures, some as simple as drawing blood and placing IV’s.  The physicians are responsible for collecting all blood specimens for urgent lab testing and for placing IV’s in those patients who are to be admitted.  I found this a bit daunting at first as I do not get much opportunity to perform such procedures at my home institution.    As when performing any procedure, I would recommend familiarizing yourself with the equipment first.  I had to remove a perfectly placed IV simply because I did not know how to secure it once it had been placed.

There is also quite a bit of obstructive uropathy secondary to benign prostatic hypertrophy.  This has given me the opportunity to replace several urinary and suprapubic catheters while I have been here.  While they have all of the supplies you will need, they are not all assembled in an organized kit.  It can be quite difficult to get everything together without the help of a nurse, and on a busy day in the A&E the help of a nurse is not always available.

I have also had the opportunity to do some suturing.  In both cases it was man versus machete, and the machete won.  Most cannot remember the last time they got a tetanus shot, so they all get one for good measure.  Most are not familiar with the term Tetanus but rather know of the disease by “Lock Jaw.”  In both cases the patients were very cooperative and the suturing went quick and easy.  I understand that sutures can be in short supply at times, so I found myself being very conservative with my thread so as not to waste.  In any case I can’t even imagine how difficult it would be to perform any of these procedures on kids, like my wife had to do!

Drew
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