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Over the past month I have had the opportunity to participate in Ward rounds at Annotto Bay Hospital, Port Antonio Hospital and at St. Anne’s Bay Hospital.  Each had their unique challenges.  Port Antonio Hospital is a local hospital in a fairly remote location.  The “house officer” on duty is in charge of both the male and female medical wards.  A lot of the cases are similar to those that I have seen in the states including Hypertensive Emergency, Hyperosmotic Hyperglycemia State, Exacerbation of Congestive Heart Failure, and Stroke.  The resources are limited, and as I have shared in previous blogs many of the diagnostic tests have to be done privately as the hospital does not own a CT scanner, Echo machine, or Ultrasound.  The “house officer” that I worked with was very kind and sought advice on how he could improve in caring for his patients.  Given the tough circumstances I think he is doing an outstanding job.

Annotto Bay hospital is a referral hospital of sorts.  The female medical ward is currently undergoing repairs after it was damaged by Hurricane Sandy.  This has required intermingling of male and female patients on the male medical ward.  There is also overflow of patients onto the male and female surgical wards.  The construction is almost done and they should be moving the patients in the coming month.  Here two “house officers” and two “interns” manage both the male and female medical wards with input from a “consultant” who is board certified in Internal Medicine.  I would equate this to the attending, senior resident, and intern model.  However, the consultant is not their everyday, and may only physically round on patients 2 or 3 times a week.  He is always available by telephone if needed.  When he is there he is quick to teach and share his experience.  Annotto Bay has similar limitations and most of the diagnostic work-up must be done privately.  They do have the ability to perform basic x-ray and laboratory tests.  The morning is filled with pre-rounding and then rounding with the consultant.  The afternoon is consumed with coordination of care and phone conferencing with specialists in Kingston.  Discharges are performed in the afternoon, and their seems to be a disconnect between the hospital and the primary care physicians at the health centers.  There really is not good way to communicate hospital details to the physicians in the community.

I have spent the last week at St. Anne’s Bay Hospital which is the regional referral center.  The hospital is about twice as large as Annotto Bay hospital which is about twice as big as Port Antonio.  The hierarchy is similar with consultants, house officers, and interns.  Annotto Bay hospital is equipped with ultrasound and fluoroscopy, however, I understand that the ultrasound machine has been over heating and they are currently limited on the number of ultrasounds that they can perform each day.  Major testing such as CT scans and echocardiograms still have to be performed privately.  They do have two beds in a “High Dependency Unit,” which would be equivalent to our ICU without ventilators.  They have telemetry, continuous pulse oximetry, and they have one nurse that cares for the two patients.  I find that the cases are a little more severe at St. Anne’s Bay.  For example, a young many with Ackee poisoning, known to cause hypoglycemia and anion gap metabolic acidosis, had to be transferred from one of the smaller local hospitals to St. Anne’s as they lacked the resources to complete his work-up and give him adequate treatment.  Even with his transfer the patient did not do well and subsequently expired.  I can’t help but wonder if his outcome would be different if the proper resources were available.  The physicians are well trained and are as efficient as the system allows.

Drew

Our last few days in Jamaica have been spent at St. Ann’s Bay Regional Hospital. It has been wonderful to see the referral hospital. The pediatric unit is large and attached in a small room is the special nursery. The nursery has 2 ventilators and the physicians and nurses are very proud that the ISSA foundation donated the ventilators. While asking about the ventilators and how they monitor the neonates on the ventilators I was shocked to learn that the portable x-ray machine broke down months ago so the neonates never get a CXR. They also have a difficult time obtaining blood gasses. They don’t have CVN and the physician told me that the babies just get D5 0.2NS and starve. It was also interesting to note that they don’t have central line kits and many times use a foley catheter for a UVC. They are very innovative in the nursery and on the wards. They have learned to rely on physical exam findings instead of labs and images.

On the pediatric ward I see lots of asthma, bronchiolitis, and URI’s. The turn around rate is fast. Most of the children stay the night and get to leave the next morning. The beds are very close together and there is only room for a small chair (like a school room chair not a nice recliner.) Many of the parents sleep in the chair overnight so they can be close to their children. The parents that have been there a long time even sleep during the day in the chair because they are so tired. The children usually just sit in there beds and color or read but, I noticed a small playroom attached that has books, a TV and some games for the kids to use. I noticed that no one ever used the playroom. This morning I arrived at the pediatric unit early and asked why none of the kids are ever in the playroom. The nurse said it was because they needed a supervisor and the nurses are usually to busy. I told them that I would supervise the children and they gave me the key to the room. The kids were excited and after breakfast came to play. They loved the room and were sad to leave when rounds started. I was sad I couldn’t play more but was sweating profoundly after pushing children in carts and entertaining them.

The resort is AMAZING. Everyone has been so wonderful to us and they call doc wherever we go. The food is amazing and there is a large variety of food. The activities are wonderful and Drew even got scuba certified so we can go diving together. I couldn’t ask for better service or a nicer place to stay. It truly has been wonderful.

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

Hello from Jamaica!

My name is Drew Behunin and I am an Internal Medicine Resident at the University of Iowa.  It has been my great privilege to be the first Internal Medicine doctor to volunteer with the Issa Trust.  Honestly, I was quite nervous before starting.  The Issa Trust is a well established entity when it comes to the Pediatric world in Jamaica, but up until now has not been involved in promoting care for adults. I have been in country for just over 2 weeks and have to say that my experience has been unforgettable.

In Jamaica, most medical graduates begin practicing right after graduation without formal residency training.  Some pursue advanced training through the university and serve as consultants.  While the physicians I have worked with did not complete residency training, they do a commendable job at taking care of patients despite the limited resources available.  I see a lot of the same diagnoses that I would see in the United States, however their management is at times more difficult.  In the United States, any patient presenting to an Emergency Room is almost guaranteed to get at CT scan of the chest, abdomen, and pelvis followed by an MRI of the brain just for good measure! 🙂  Not so here in Jamaica.  Most advanced diagnostic tests including ultrasound, CT scans, echocardiograms, stress testing, spirometry, and even some basic laboratory studies are only available in the private sector.  While these tests are cheaper than they are in the States, they are often outside of the financial capability of the patients.

Hypertension seems to be running rampant among adults.  While many are getting appropriate treatment, I believe there is a greater population that have yet to be diagnosed.  I have spent the majority of my time working in the Accident and Emergency Department and have seen a lot of patients who present for other reasons and also happen to have blood pressures in the 190/100 range.  In these situations it is a no brainer to treat.  However, there are many who come with a blood pressure in the 140/90 range.  I refer these patients back to their local health center for repeat screening, however, there is no great way to relay this need to the health center nor guarantee the patient will follow through.  I am convinced that uncontrolled hypertension is contributing to the rising mortality from cardiovascular disease.  The majority of my time on the Medicine Wards at Anotto Bay Hospital is spent caring for patients suffering from stroke, heart failure, and the consequences of diabetes.  I was relieved to see that all of the major cardiovascular medications are readily available including ACE inhibitors, statins, and diuretics.  Through all of this I have learned to depend on my physical exam skills and clinical intuition, both of which are invaluable tools in the long run.